The AHRQ review14 located eight RCTs of azelaic acid in mild-to-moderate acne (see Web Table 13.3). The comparators used were placebo,71 vehicle,72 benzoyl peroxide,61 tretinoin,72 oral tetracycline73,74 and in combination with glycolic acid versus tretinoin.75 One further RCT published in German evaluated its efficacy against 2% erythromycin.76,77
In papulopustular acne 20% azelaic acid has similar efficacy at 5 or 6 months to 0-05% tretinoin,72 5% benzoyl peroxide,61 2% topical erythromycin77 and oral tetracycline 1 g/day,73,74 with consistent percentage reductions in median IL of 80-84%. Across the studies, good-to-excellent improvement occurred in 71-82% of individuals. In comedonal acne 20% azelaic acid has similar activity to 0-05% topical isotretinoin, with 79% and 82% reduction in comedonal counts, respectively, and good or excellent improvement in 59% and 63% of the 289 patients at 6 months.72
of reactions were categorised as "marked". In the clinical studies, which also included postmarketing evaluations, 0-5% of individuals experienced scaling, 5-23% burning and 13-29% itching. Azelaic acid is not known to cause photosensitivity and sublethal doses do not promote P. acnes resistance.78 Azelaic acid is better tolerated than benzoyl peroxide,61 and tretinoin72,75 and it does not bleach clothing or hair. It is used in hyperpigmentary skin disorders, but has not been shown to have depigmentatory effects in acne patients77 suggesting that it preferentially targets abnormal melanocytes.
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