INGREDIENT · ACID
Azelaic acid for skin: benefits, side effects and pregnancy
Azelaic acid is popular in India for dark patches and for acne, partly because it is gentler than the alternatives people compare it with. The evidence is better than for many cosmetic actives, and it is worth knowing where it comes from.
You may see it written as
- Azelaic Acid
What azelaic acid is
A 2015 evidence review describes azelaic acid as a complex molecule with many activities. It is anti-infective and anti-inflammatory, and it inhibits the build-up of keratin in hair follicles and the production of melanin, the skin’s pigment.1 That mix is why it is used for both breakouts and dark patches.
The same review sets out the quality of the evidence behind each use, which is a good habit to keep: azelaic acid has been studied for more conditions than it has strong evidence for.1
What it does for dark patches and acne
The best-known comparison is with hydroquinone. In a 24-week double-blind study of 329 women with melasma, a 20% azelaic acid cream and a 4% hydroquinone cream were each used with a broad-spectrum sunscreen. Azelaic acid produced 65% good or excellent results, with no significant difference between the two creams.2
A study in 30 Indian patients with melasma used 20% azelaic acid twice daily for 24 weeks on one side of the face. On the other side, patients used a potent steroid cream for 8 weeks and then azelaic acid. The side with the steroid first lightened more at 4, 8 and 16 weeks.3 The authors note that response to azelaic acid alone is rather slow.3 A potent steroid is a prescription decision, not a skincare routine.
For acne, a Cochrane review found that azelaic acid is probably less effective than benzoyl peroxide, and probably makes little or no difference compared with tretinoin, both on moderate-quality evidence. Against clindamycin it may make little or no difference, and against adapalene the evidence was too weak to say. For most other comparisons, the quality was low or very low.4
Side effects and tolerability
In the 329-woman melasma study, severe side effects such as allergic sensitisation and exogenous ochronosis, a skin darkening seen with some lightening creams, were not observed with azelaic acid.2
In the acne review, azelaic acid could not be compared reliably with benzoyl peroxide or adapalene on minor side effects, because the evidence was very low quality. It showed no clear difference from clindamycin. Where it was compared with tretinoin, application-site reactions such as scaling were reported.4
If something stings or reddens your skin, stop using it and see whether it settles. Adding one new product at a time makes it easier to tell which one was responsible.
Using azelaic acid with other products
We did not find a source saying azelaic acid must be kept apart from another active. What exists is mostly treatments compared against each other, rather than combined.
Those studies do not show what happens when you layer two products you bought separately, so read each row as what has been tried, not as proof of a good match.
Sunscreen
Studied togetherBoth melasma studies above had patients use a broad-spectrum sunscreen alongside the cream.2,3
Retinoids (tretinoin)
No good evidenceThe background of the Indian melasma study mentions earlier work combining azelaic acid with topical retinoic acid, but we did not find that work, so we cannot describe its results.3
Hydroquinone and benzoyl peroxide
No good evidenceThe studies above compared azelaic acid with each of these rather than combining them.2,4 We found no study of using them together.
Niacinamide and other actives
No good evidenceWe have not found studies on layering azelaic acid with these that we can cite. Add one at a time, so that if your skin reacts you know which product did it.
Recommended: a source advises it. Studied together: a published study used both in one product. Take care: a source gives a reason for caution. Avoid together: a source says not to combine them. No good evidence: we looked and found nothing we can cite.
Azelaic acid in pregnancy and breastfeeding
We found no pregnancy- or lactation-specific evidence for this ingredient.
No pregnancy-specific evidence is not the same as safe, or as unsafe.
There is one useful data point, with a catch. A large Nordic registry study of about 3.9 million infants used first-trimester exposure to topical azelaic acid or clindamycin as a comparison group for topical retinoids. Among the 11,139 exposed to one of those two, 2.6% had a major malformation, against 3.0% of unexposed infants.5 The study was built to ask about retinoids, and it pooled the two medicines, so it is not a safety study of azelaic acid.
Evidence on cosmetic products in pregnancy is limited overall, so ask your doctor or midwife about the specific product you use.6
What you will see on the label
Azelaic acid is usually listed as Azelaic Acid, often with a percentage on the front of the pack. The trials above used 20%,2,3 so compare that with what your product contains before reading across their results.
Snifff shows azelaic acid as Low risk. For the rest of the formula, see what the score means and how to read the list.
As Snifff shows itAzelaic Acid
Pregnancy and nursing
We found no pregnancy- or lactation-specific evidence for this ingredient.
Wording as it appears in the extension, which can change between releases.
A FEW MORE ANSWERS
Common questions about azelaic acid
Is azelaic acid as good as hydroquinone?
In a 24-week double-blind study of 329 women with melasma, a 20% azelaic acid cream and a 4% hydroquinone cream showed no significant difference in overall results.2 That was one study, from 1991.
How long does azelaic acid take to work?
The melasma studies ran for 24 weeks, and the authors of the Indian study describe the response to azelaic acid alone as rather slow.3 Expect weeks to months, not days.
Is azelaic acid a steroid?
No. In the Indian melasma study, azelaic acid and a steroid cream were two separate products.3
Is azelaic acid better than benzoyl peroxide for acne?
The Cochrane review found azelaic acid probably leads to a worse treatment response than benzoyl peroxide, on moderate-quality evidence.4
Is azelaic acid safe in pregnancy?
Snifff found no pregnancy-specific evidence for Azelaic acid. Ask your doctor or midwife about the product you use.
WHERE THIS COMES FROM
Sources
- Azelaic acid: evidence-based update on mechanism of action and clinical applicationSchulte BC, Wu W, Rosen T · Journal of Drugs in Dermatology · 2015
- The treatment of melasma: 20% azelaic acid versus 4% hydroquinone creamBaliña LM, Graupe K · International Journal of Dermatology · 1991
- A comparative study of 20% azelaic acid cream monotherapy versus a sequential therapy in the treatment of melasma in dark-skinned patientsSarkar R, Bhalla M, Kanwar AJ · Dermatology · 2002
- Topical azelaic acid, salicylic acid, nicotinamide, sulphur, zinc and fruit acid (alpha-hydroxy acid) for acneLiu H, et al. · Cochrane Database of Systematic Reviews · 2020
- Topical retinoid use in women of reproductive age and risk of major congenital malformations in exposed pregnancies: a Nordic cohort studyRefsum E, et al. · British Journal of Dermatology · 2026
- Cosmetic dermatology in pregnancy and lactation: a risk-benefit framework for clinical practiceKovacs T, et al. · International Journal of Dermatology · 2026
This page explains an ingredient. It is not medical advice, and it is not an assessment of any product. If you are pregnant, breastfeeding, or have a skin condition, ask your doctor or pharmacist.