GradedHealth

Azelaic acid for acne, rosacea and dark spots: what the trials show

Azelaic acid cream clears rosacea bumps and redness and helps acne and melasma in trials, often as well as standard creams. It has not been tested for wrinkles.

Published October 2026

Short answer

Azelaic acid beat plain cream for rosacea, acne and melasma in randomized trials, with the strongest evidence for rosacea, and often matched standard treatments. No trials have tested it for skin aging. Evidence grade B (Moderate). Systematic review of 43 randomised trials and Cochrane reviews; high-certainty for rosacea, but acne head-to-head evidence is moderate to low quality, so the combined answer is downgraded once.

Key takeaways

  • In 20 rosacea trials, azelaic acid beat plain cream after 12 weeks for redness, inflamed bumps and clear skin, and it beat metronidazole 0.75% [1].
  • For acne, azelaic acid beat plain cream in 16 trials, but it was probably slightly less effective than benzoyl peroxide (risk ratio 0.82) and about as effective as tretinoin [1][2].
  • For melasma, 20% azelaic acid beat plain cream in seven trials and beat 2% hydroquinone on global improvement, with irritation in 18.7% of users versus 50.9% for hydroquinone combinations [1][3].
  • Ivermectin cream did better than azelaic acid for rosacea bumps in a 2025 meta-analysis of 21 trials [4].
  • No eligible trials tested it for skin aging, and narrative reviews (not trials) say it can be used in pregnancy for mild acne [1][5].

The short version

Azelaic acid is one of the topical treatments with high-quality evidence for rosacea [6], and it also helps acne and melasma (dark patches on the face). A 2023 review of 43 randomized trials found it beat plain cream (vehicle) for all three, and for rosacea it also beat metronidazole 0.75% [1]. It is often about as good as standard treatments, and no trials have tested it for skin aging [1].

What the studies show

Rosacea. In 20 rosacea trials, azelaic acid improved redness, inflamed bumps, overall improvement and the chance of clear skin compared with vehicle after 12 weeks, and it did better than metronidazole 0.75% [1]. A Cochrane review rated the evidence for azelaic acid high quality, and in four trials patients were more likely to report improvement than with placebo (risk ratio 1.46, 95% CI 1.30 to 1.63) [6]. Ivermectin cream did better than azelaic acid in a 2025 meta-analysis of 21 trials [4].

Acne. Sixteen acne trials found azelaic acid beat vehicle on overall assessments and acne severity [1]. Compared head to head, a Cochrane review judged it probably slightly less effective than benzoyl peroxide (risk ratio 0.82, 95% CI 0.72 to 0.95) and probably about as effective as tretinoin (0.94, 0.78 to 1.14) [2]. The 2024 US acne guidelines make only a conditional recommendation for it, compared with strong recommendations for benzoyl peroxide and topical retinoids [7].

Melasma and dark patches. In seven melasma trials, 20% azelaic acid was better than vehicle for severity and overall improvement, and better than 2% hydroquinone on global improvement [1]. A meta-analysis of 45 studies (2,359 patients) found azelaic acid worked about as well as hydroquinone, cysteamine and tranexamic acid [3].

The nuances

Irritation. Irritation was reported in 18.7% of people using azelaic acid for melasma, compared with 50.9% for hydroquinone combinations [3]. Very few differences from other treatments were seen in common side effects [1].

Mixed results by use. Azelaic acid gel may make no difference to perioral dermatitis severity after 6 weeks, based on low-certainty evidence [8].

Skin aging. No eligible randomized trials tested azelaic acid for skin aging [1].

Pregnancy. Narrative reviews say topical treatments such as azelaic acid can be used for mild-to-moderate acne in pregnancy and breastfeeding, but those reviews are not trials [5].

What this means for you

For rosacea bumps and redness, acne and melasma, azelaic acid has randomized trial support and is often as good as familiar alternatives [1][6]. Results take weeks (the rosacea comparisons were at 12 weeks) [1]. A pharmacist or dermatologist can say which strength suits you and whether another treatment fits better. For more, see Azelaic Acid.

Go deeper

  • Azelaic Acid — Azelaic acid cream or gel beat plain cream (vehicle) for rosacea, acne and melasma in randomized trials, with high-certainty evidence for rosacea.

References

  1. A systematic review to evaluate the efficacy of azelaic acid in the management of acne, rosacea, melasma and skin aging.. J Cosmet Dermatol, 2023.
  2. Topical azelaic acid, salicylic acid, nicotinamide, sulphur, zinc and fruit acid (alpha-hydroxy acid) for acne.. Cochrane Database Syst Rev, 2020.
  3. Efficacy and safety of topical agents in the treatment of melasma: What's evidence? A systematic review and meta-analysis.. J Cosmet Dermatol, 2023.
  4. Efficacy of Widely Used Topical Drugs for Rosacea: A Systematic Review and Meta-Analysis.. Actas Dermosifiliogr, 2025.
  5. Treatment of Acne Vulgaris During Pregnancy and Lactation: A Narrative Review.. Dermatol Ther (Heidelb), 2023.
  6. Interventions for rosacea.. Cochrane Database Syst Rev, 2015.
  7. Guidelines of care for the management of acne vulgaris.. J Am Acad Dermatol, 2024.
  8. Pharmacological interventions for periorificial (perioral) dermatitis in children and adults: a systematic review.. J Eur Acad Dermatol Venereol, 2022.