Azelaic Acid: The Quiet Achiever — And How It Pairs With Tretinoin

Azelaic acid rarely gets the attention that retinoids or vitamin C do, but it's one of the most useful and best-tolerated topicals I prescribe. Azelaic acid is a  naturally occurring dicarboxylic acid found in grains like wheat, rye and barley, and it works in several ways at once.

How azelaic acid works: mechanism of action and skin benefits

Azelaic acid is genuinely multi-tasking. It calms inflammation (partly by blocking kallikrein-5 and cathelicidin, two drivers of rosacea), reduces Cutibacterium acnes, normalises the way skin cells shed so pores block less easily, and helps inhibit tyrosinase, the enzyme that makes pigment. That last property is why it's so valuable for melasma and for the brown marks left behind after acne.

This combination of antimicrobial and anti-inflammatory properties explains several benefits of azelaic acid, particularly for rosacea and acne, redness, hyperpigmentation from acne and uneven skin tone.

The evidence is solid. A 2023 systematic review of 43 randomised controlled trials found azelaic acid significantly outperformed placebo for rosacea (redness and inflammatory lesions), acne and melasma. For melasma, 20% azelaic acid outperformed 2% hydroquinone cream. The American Academy of Dermatology's 2024 acne guidelines conditionally recommend it, based on moderate-certainty evidence. That supports topical azelaic acid as a treatment option for mild to moderate acne vulgaris as well as rosacea.

Two practical advantages matter to my patients: it doesn't make skin sun-sensitive, and it's considered safe in pregnancy and breastfeeding which  is a period when tretinoin must be stopped. In Australia, azelaic acid products include 20% cream and 15% gel.

How to use azelaic acid alongside tretinoin: the pros 

Used thoughtfully, azelaic acid and tretinoin can complement each other well. They target different concerns, which can make the combination useful for people dealing with acne, pigmentation, redness or signs of ageing.

Azelaic acid and tretinoin cover each other's gaps. Tretinoin is the stronger comedolytic and anti-ageing agent; azelaic acid adds antibacterial, anti-redness and anti-pigment action that tretinoin doesn't offer to the same degree.

Better results in pigment. In an open trial of 48 patients with melasma, 79% using 20% azelaic acid plus tretinoin achieved a good or excellent result versus 71% on azelaic acid alone. It's a small, unblinded study, so treat that as encouraging, not definitive.

It offsets a retinoid downside. Early tretinoin use often causes irritation, and in deeper skin tones that irritation can itself trigger pigmentation. Azelaic acid works against that.

Easy timing. Because azelaic acid isn't photosensitising, it suits the morning, with tretinoin at night, so the two don't have to be layered at all.

Using azelaic acid with tretinoin: the cons 

The combination is not right for everyone, particularly if your skin is already sensitive or easily irritated. Using two active treatments at once can add complexity to a routine and may increase the risk of dryness, stinging or inflammation.

Irritation stacks. Both can sting, dry and flake. Used together too enthusiastically, you get a compromised barrier, and inflamed skin makes pigmentation worse, not better.

More steps, less consistency. The best routine is the one you'll actually do for six months, which is roughly how long azelaic acid takes for maximum benefit.

Rare hypopigmentation. Azelaic acid can occasionally lighten surrounding skin, which is more noticeable in darker skin tones.

Limited combination data. Most trials study these agents separately. The pairing is reasonable and widely used, but under-researched.

Azelaic acid vs salicylic acid, glycolic acid and benzoyl peroxide

Azelaic acid is a dicarboxylic acid, so it is not the same type of acid as salicylic acid or glycolic acid. Salicylic acid is a beta hydroxy acid, often called salicylic acid or BHA, while glycolic acid is an alpha-hydroxy acid. 

These acids are usually chosen more for exfoliation and pore-clearing, while azelaic acid has antimicrobial and anti-inflammatory properties as well as effects on pigmentation.

Azelaic acid and salicylic acid can sometimes sit in the same routine, and some people use azelaic acid and benzoyl peroxide for acne, but too many active ingredients at once can increase dryness and sensitivity. I would introduce them slowly, particularly with sensitive skin.

How I usually start people with azelaic acid

Azelaic acid in the morning, tretinoin two or three nights a week, building up as tolerated, moisturiser over both, sunscreen daily. I generally advise patients to cleanse gently first, then apply azelaic acid, moisturiser and a broad-spectrum sunscreen with SPF 30 or higher in the morning. Give it 12 weeks before judging. If your skin turns raw, that's a signal to reduce frequency, not to push on.

If you're unsure which is right for your skin, our dermatologists at Skindepth can tailor it properly.

This article is general information and is not a substitute for individual medical advice.

Frequently asked questions

What are azelaic acid’s benefits and main uses?

The main uses of azelaic acid include acne, rosacea and hyperpigmentation. The benefits of azelaic acid come from the way it targets several processes at once, including inflammation, acne-causing bacteria, blocked pores and pigment production. For rosacea, it helps to improve redness and inflammatory lesions. It can also be useful for post-acne marks and uneven skin tone, particularly when hyperpigmentation and acne occur together.

How is azelaic acid used for acne and rosacea?

Azelaic acid is used to treat acne and rosacea as a topical treatment applied after you cleanse the skin. For the treatment of acne, it is particularly useful for mild to moderate acne vulgaris. Depending on the formulation and treatment plan, it may be used once or twice a day, and some formulations are directed twice daily. Follow the directions for your specific cream or gel rather than assuming every product is used the same way.

Is azelaic acid safe for sensitive skin?

For many people, azelaic acid is safe and well tolerated, including some people with sensitive skin, although stinging, dryness, redness or itching can still occur. Its tolerability is one reason it is often considered a relatively gentle skin care ingredient. Treatment with azelaic acid should still be introduced gradually, especially alongside other active ingredients. If your skin becomes persistently sore or inflamed, speak with your dermatologist.

Can I use azelaic acid and benzoyl peroxide together?

Yes, some people can use azelaic acid and benzoyl peroxide in the same acne routine, but that does not mean both should always be introduced at once. They work differently and combining active treatments can make dryness or sensitivity more noticeable. A dermatologist may suggest separating them by time of day or using them on different days, particularly if you have sensitive skin or are already using a retinoid.

Azelaic acid vs salicylic acid and glycolic acid: what's the difference?

In an azelaic acid vs salicylic acid comparison, the main difference is how the ingredients work. Salicylic acid or BHA is a hydroxy acid used mainly to exfoliate inside pores, while glycolic acid is an alpha-hydroxy acid that exfoliates the skin surface. Azelaic acid works differently, with antimicrobial, anti-inflammatory and pigment-regulating effects, so the better choice depends on whether acne, redness, texture or pigmentation is the main concern.

Can I use azelaic acid with niacinamide, hyaluronic acid or vitamin C?

Yes, azelaic acid with niacinamide or hyaluronic acid can often fit into the same routine, while vitamin C may also be used depending on your skin and the formulation. Vitamin C is commonly used for antioxidant support against free radicals and pigmentation. The main consideration is how well your skin tolerates multiple products, so introduce new active ingredients gradually and keep moisturiser and sunscreen in the routine.

How long does treatment with azelaic acid take to work?

Treatment with azelaic acid takes time. Some people may notice early improvement within four to six weeks, but the effects of azelaic acid are usually better judged over several months. For acne, redness or pigmentation, consistency matters more than increasing frequency too quickly. If there is little improvement after a reasonable trial, or your skin is struggling to tolerate the product, a dermatologist can review whether azelaic acid is right for you.

Can you use azelaic acid during pregnancy?

Azelaic acid is one of the topical acne options commonly considered during pregnancy, but individual medical advice still matters. The safety of azelaic acid should be discussed with your doctor, dermatologist or pharmacist, particularly if you use other treatments. Tretinoin, by contrast, is generally stopped during pregnancy. If you are pregnant, planning pregnancy or breastfeeding, it is best to review your entire skincare routine rather than assessing one ingredient in isolation.