Azelaic Acid for Acne and Rosacea
The topical that treats spots and the marks they leave at the same time — and one of the few usable in pregnancy. How it works, cream or gel, and who it suits.
Part of the Complete Acne Guide.
Key fact: Azelaic acid is the unusual one among acne treatments — it treats spots and the marks they leave at the same time, it is well tolerated on dry and sensitive skin, and it is one of the very few options that can be considered in pregnancy. It is also slower than most, and that trade-off is the whole story.
What Skinoren is
Skinoren is the brand name for azelaic acid, a naturally occurring acid found in grains including wheat, rye and barley. It is a prescription topical treatment in the UK, available as a 20% cream and a 15% gel.
It sits slightly apart from the rest of the acne shelf. Most acne treatments do one thing well: benzoyl peroxide kills bacteria, retinoids unblock follicles, antibiotics reduce inflammation. Azelaic acid does a moderate amount of several of those things and adds one that none of the others do — it acts on pigmentation.
How azelaic acid works
Antibacterial
Reduces Cutibacterium acnes, the bacterium that proliferates in blocked, oil-rich follicles. It does this without the resistance problem that applies to antibiotics.
Comedolytic
Normalises the way cells shed inside the follicle, so pores block less readily — the step that prevents a spot rather than treating one.
Anti-inflammatory
Reduces the inflammatory response, which is why it helps the redness around lesions and is useful in rosacea as well as acne.
Tyrosinase inhibition
Interferes with the enzyme that produces melanin in overactive pigment cells, which is what makes it useful against the marks acne leaves behind.
That fourth mechanism is the one worth knowing about, because it is unusual. It also appears to be relatively selective for overactive pigment cells, which is why azelaic acid does not lighten surrounding normal skin the way some other pigment treatments can.
Cream or gel
| 20% cream | 15% gel | |
|---|---|---|
| Strength | Higher concentration | Lower concentration, but formulated for better penetration — the two are broadly comparable in effect |
| Feel | Richer, more emollient, can leave a slight film | Lighter, absorbs quickly, no residue |
| Suits | Dry, normal or sensitive skin; colder months | Oily or combination skin; under make-up; warmer weather |
| Licensed mainly for | Acne, and pigmentation | Rosacea, and acne |
| Stinging | Generally milder | Slightly more likely initially |
In practice the choice is driven by skin type and preference far more than by potency. The formulation someone will actually use twice a day is the one that works.
What it treats
- Acne vulgaris — particularly mild to moderate acne with a mixture of blackheads, whiteheads and inflammatory spots. A practical choice where retinoids or benzoyl peroxide have proved too irritating.
- Papulopustular rosacea — the spots-and-redness form. Its anti-inflammatory action suits rosacea-prone skin, which tolerates most acne treatments badly. See our rosacea guide.
- Post-inflammatory hyperpigmentation — the brown marks left after spots heal, which are frequently more troubling than the acne itself. Covered in acne scars and marks.
- Melasma — symmetrical patches of pigmentation, often hormonal, on the cheeks, forehead and upper lip.
It does not treat scarring. A true scar is a change in the texture of the skin and no cream alters that; azelaic acid acts on flat pigmented marks, which is a different thing and a much more common one.
Why it helps marks as well as spots
This is the reason azelaic acid is frequently the right choice for people with darker skin tones, where post-inflammatory hyperpigmentation is both more common and more persistent, and often the main complaint.
The sequence matters. Every inflamed spot triggers pigment production, so marks accumulate as long as acne is active. A treatment that reduces new lesions and acts on the pigment left by old ones is working on both ends of that cycle at once — whereas a treatment that clears spots while doing nothing for marks leaves someone with clear skin they are still unhappy with.
Sunscreen is not optional alongside it. Ultraviolet light drives the same pigment cells the treatment is trying to quieten. Using azelaic acid for pigmentation without daily sunscreen is close to pointless, and this is the single commonest reason it appears not to work on marks.
Tolerability, and who it suits
Azelaic acid is generally the best tolerated of the effective topical acne treatments, which is its main practical advantage. Mild stinging, tingling or warmth in the first couple of weeks is common and usually settles as the skin adapts.
It does not cause the sun sensitivity that retinoids and some antibiotics do, and it does not bleach fabric the way benzoyl peroxide does — two small things that remove two common reasons people stop.
It particularly suits people who have tried a retinoid or benzoyl peroxide and found their skin too irritated to continue, people with dry or sensitive skin, people with rosacea as well as acne, and people whose main concern is pigmentation.
Its disadvantage is speed. It works more slowly than a retinoid and is generally less potent for heavily comedonal acne. Expect to judge it at twelve weeks rather than six.
Pregnancy and breastfeeding
This is one of the more useful things about azelaic acid, and worth stating carefully.
Most effective acne treatments are unavailable in pregnancy. Topical and oral retinoids are contraindicated, and the tetracycline antibiotics are not used. That leaves a narrow set of options at exactly the point when hormonal changes commonly make acne worse.
Azelaic acid is minimally absorbed through the skin and is among the small number of treatments that may be considered during pregnancy and breastfeeding. That is a decision for a clinician who knows your circumstances rather than something to start on your own — but if you are pregnant, trying, or breastfeeding, it is worth raising by name.
Combining it with other actives
| Alongside | Position |
|---|---|
| A topical retinoid (adapalene, tretinoin) | Commonly combined, and they work on different steps. Usually alternated or split between morning and evening rather than layered, to limit irritation |
| Benzoyl peroxide | Can be used together, typically at different times of day. Both are drying, so introduce one at a time |
| Oral antibiotics | A sensible pairing — azelaic acid provides the topical component that an oral antibiotic should always have alongside it |
| Niacinamide, or a plain moisturiser | No problem, and moisturiser makes a course considerably easier to complete |
| Strong exfoliating acids, scrubs | Unnecessary and counterproductive. Azelaic acid is already doing that job, and stacking them irritates skin into abandoning treatment |
The practical rule when adding anything: one new thing at a time, two to four weeks apart, so that if skin reacts you know what to.
How it compares with the alternatives
| Treatment | Stronger on | Weaker on |
|---|---|---|
| Azelaic acid | Tolerability, pigmentation, rosacea, pregnancy options | Speed; heavily comedonal acne |
| Topical retinoid | Blackheads and whiteheads, long-term maintenance, texture | Irritation, sun sensitivity, not usable in pregnancy |
| Benzoyl peroxide | Inflammatory spots, speed, preventing antibiotic resistance | Dryness, bleaching fabric, does nothing for pigmentation |
| Topical antibiotic | Inflammation | Resistance — never used alone |
For what a course looks like week by week, including the purge and a workable routine around it, see our guide to Skinoren for acne. For maintaining clear skin afterwards, see acne maintenance and relapse. What is available is set out on our acne treatment page.
Frequently Asked Questions
What is azelaic acid and how is it different from other acne treatments?
Azelaic acid is a naturally occurring acid, sold in the UK as Skinoren in a 20% cream and a 15% gel. It differs from other topical treatments by doing several things moderately rather than one thing strongly: it reduces acne bacteria, helps unblock follicles, calms inflammation, and — unusually — acts on pigmentation. That last property means it treats the brown marks left by spots as well as the spots themselves, which no other standard acne treatment does.
Should I use the cream or the gel?
It depends on your skin rather than on strength — the 20% cream and 15% gel are broadly comparable in effect, because the gel is formulated to penetrate better at the lower concentration. The cream is richer and suits dry, normal or sensitive skin and colder weather. The gel is lighter, absorbs quickly and suits oily or combination skin and wearing make-up. The one you will use consistently is the right one.
Does azelaic acid help with dark marks left by acne?
Yes, and it is one of the few acne treatments that does. It inhibits the enzyme that produces melanin in overactive pigment cells, which is what causes post-inflammatory hyperpigmentation — the brown marks left after spots heal. It appears relatively selective for overactive cells, so it does not tend to lighten surrounding normal skin. Daily sunscreen is essential alongside it, because ultraviolet light drives the same pigment cells.
Can azelaic acid be used in pregnancy?
It is among a small number of acne treatments that may be considered in pregnancy and breastfeeding, because very little is absorbed through the skin. That matters because most effective options are unavailable — topical and oral retinoids are contraindicated and tetracycline antibiotics are not used — at a time when hormonal changes often make acne worse. It is still a decision for a clinician who knows your circumstances, but it is worth raising by name.
Is azelaic acid as effective as a retinoid or benzoyl peroxide?
It is generally slower and somewhat less potent for heavily comedonal acne than a topical retinoid, and less rapid than benzoyl peroxide for inflammatory spots. Its advantages lie elsewhere: it is considerably better tolerated, it does not cause sun sensitivity, it does not bleach fabric, it treats pigmentation, and it suits rosacea-prone skin. For someone who could not continue a retinoid because of irritation, the more effective treatment is the one they can actually keep using.
References
- National Institute for Health and Care Excellence. Acne vulgaris: management (NG198). nice.org.uk
- National Institute for Health and Care Excellence. Clinical Knowledge Summary: Acne vulgaris. cks.nice.org.uk
- NHS. Acne. nhs.uk
- British Association of Dermatologists. Patient information leaflets and isotretinoin guidance. bad.org.uk
- Medicines and Healthcare products Regulatory Agency. Isotretinoin: Pregnancy Prevention Programme and safety review. gov.uk
- DermNet. Acne and acneiform eruptions. dermnetnz.org
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Several acne treatments, including oral retinoids and the tetracycline antibiotics, must not be used in pregnancy or when there is any chance of becoming pregnant. Acne treatment takes weeks to months to work and a short-lived worsening at the start is common. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.