Azelaic Acid for Rosacea: What the Evidence Says
Azelaic acid for rosacea can help inflammatory papules and pustules, especially with the UK prescription gel licensed for that presentation. Evidence is less certain for flushing or lasting background redness alone, and it does not show that visible facial vessels will disappear. The right treatment depends on which rosacea features are present and whether the diagnosis is correct.
The named rosacea medicines below require a prescription in the UK. This guide explains their evidence and product labels. A prescriber can advise which treatment suits your skin.
What rosacea symptoms can azelaic acid address?
Azelaic acid is most relevant to papules and pustules in papulopustular rosacea; flushing, persistent redness and visible vessels are different features. The NHS rosacea guide and British Association of Dermatologists patient leaflet describe overlapping patterns, including facial redness that comes and goes, spots and possible eye symptoms.
Rosacea can resemble acne, though they are separate diagnoses. Some people mainly flush or have persistent erythema, while others develop inflammatory bumps. Evidence for a treatment on bumps does not show that it controls every form of redness.
Common rosacea features include:
- Flushing or lasting facial redness.
- Papules and pustules.
- Visible small blood vessels.
- Eye symptoms can also occur.
The Primary Care Dermatology Society rosacea guidance places azelaic acid among topical options for papules and pustules. The evidence does not support describing azelaic acid as a way to remove established telangiectasia, the small visible vessels that can occur with rosacea.
Does azelaic acid for rosacea calm redness?
Azelaic acid 15% gel reduced inflammatory lesions in vehicle-controlled trials, and some participants also had improved erythema scores. Those findings concern diagnosed papulopustular rosacea and cannot predict the result for an individual. The trials enrolled people with papulopustular rosacea; they do not show whether azelaic acid helps flushing or persistent redness on its own.
A 2003 report of two multicentre, double-blind, randomised phase III studies compared 15% gel with vehicle in people with moderate papulopustular rosacea. Among 329 and 335 participants, lesion counts fell by 58% versus 40% and 51% versus 39%; erythema improvement was reported in 44% versus 29% and 46% versus 28% (PubMed study record). The Finacea product information describes the trials as lasting 12 weeks.
A separate 15-week, randomised head-to-head study of 251 people compared azelaic acid 15% gel with metronidazole 0.75% gel. It reported greater mean lesion-count reduction with azelaic acid and erythema improvement in 56% versus 42%; neither treatment had a clinically appreciable effect on telangiectasia (PubMed study record). This was one trial, so it cannot establish that azelaic acid is always better.
These are average changes among trial participants. The erythema score cannot predict an individual response or show that every kind of facial redness will improve.
A Cochrane review of 106 studies and 13,631 participants with rosacea found azelaic acid more effective than placebo in participant assessments, with a relative risk of 1.46 and 95% confidence interval from 1.30 to 1.63. The review said three studies comparing azelaic acid with metronidazole had contradictory results (Cochrane review on PubMed). A later phenotype-based review found high-certainty evidence for azelaic acid and ivermectin in reducing papules and pustules (systematic review on PubMed).
The abstracts give no results by skin tone, and the findings cannot be assumed to apply to every cosmetic serum, cream or concentration. Our guide to reading azelaic acid before-and-after claims explains why images alone cannot establish a treatment effect.
Which azelaic acid products are prescribed in the UK?
Finacea 15% gel is a UK prescription-only medicine licensed for papulopustular rosacea; Skinoren 20% cream is a prescription-only medicine licensed for acne vulgaris. The Finacea SmPC lists the rosacea indication, while the Skinoren SmPC lists acne.
| Product | UK formulation and licence | Product-information directions | Commonly listed local reactions |
|---|---|---|---|
| Finacea | 15% gel; papulopustular rosacea | Apply to affected areas twice daily as directed by the prescriber and leaflet | Burning, pain and itching are very common; dryness is common |
| Skinoren | 20% cream; acne vulgaris | Apply to affected areas twice daily as directed by the prescriber and leaflet | Burning, itching and redness are very common; dryness is common |
The Finacea and Skinoren product information defines “very common” as affecting at least 1 in 10 people in the relevant data, and “common” as at least 1 in 100 but fewer than 1 in 10. These frequency categories do not predict what will happen to one person.
Azelaic acid 15% vs 20%
The two percentages refer to different UK medicines, vehicles and licensed indications. Rosacea trial evidence here centres on Finacea 15% gel. Skinoren 20% cream has a different evidence base and no UK rosacea licence. A prescriber can advise which product suits the diagnosis.
Both named products are prescription-only medicines. Do not use another person’s medicine or change a prescribed product or schedule yourself. Our azelaic acid range lists the products on this site; a category page is not a clinical assessment or a prescribing route.
How does azelaic acid compare with metronidazole or ivermectin?
Azelaic acid, metronidazole and ivermectin are topical options used for inflammatory papules and pustules, but the evidence does not identify one universal choice for every rosacea presentation.
| Option | What the supplied evidence supports | Limit to keep in mind |
|---|---|---|
| Azelaic acid 15% gel | Vehicle-controlled trials and reviews support improvement in papules and pustules | Stinging and other local reactions can limit use; evidence is product-specific |
| Metronidazole | A comparator in rosacea trials and an option in clinical guidance | One head-to-head trial favoured azelaic acid, while the Cochrane comparisons were contradictory |
| Ivermectin | A phenotype-based systematic review found high-certainty evidence for reducing papules and pustules | This does not establish that it suits every person or redness pattern |
The cited comparisons concern inflammatory lesions; they do not establish equal effects on flushing or visible vessels. Discuss a change with the prescriber. The 2023 systematic review of randomised trials included 20 rosacea studies in its meta-analysis and reported improvement versus vehicle after 12 weeks, though its abstract gives no effect sizes (review on PubMed).
How is prescribed azelaic acid used and reviewed?
Follow the directions for the exact medicine dispensed and the prescriber’s advice. The Finacea SmPC says to apply the gel to affected skin twice daily; the Skinoren SmPC also says twice daily for its acne indication.
The Finacea SmPC says a distinct improvement generally becomes apparent after four weeks. If there is no improvement after two months or rosacea worsens, it says to discontinue Finacea and consider other options. This is a review point in the product information. A severe reaction needs attention sooner.
- Follow the directions on the medicine supplied to you.
- Ask the prescriber before changing the product or schedule.
The Finacea SmPC warns that other topical medicines and skincare products that can irritate may need to be avoided during treatment. If you are also considering a retinoid, read our azelaic acid and tretinoin combination guidance and discuss the plan with the prescriber; the rosacea trials cited here do not establish that the combination is beneficial or suitable.
Gentle skin care and daily sun protection form part of NHS self-care advice, which recommends sunscreen of at least SPF 30. Triggers vary, so heat, sunlight, alcohol, spicy food, hot drinks, exercise or stress may worsen symptoms for some people, but a generic list does not mean everyone needs to avoid them.
For wider topical irritation context, see azelaic acid use and irritation guidance and our notes on sensitive skin and topical irritation. Do not add exfoliating products or increase application frequency to speed up a response. Ask the prescriber or pharmacist how to handle other medicines and skincare in your own routine.
Finacea’s trial results concern diagnosed papulopustular rosacea. They do not establish that a different product will work the same way.
Azelaic acid in pregnancy
The Finacea and Skinoren SmPCs advise caution when prescribing azelaic acid during pregnancy and state there are no adequate, well-controlled studies of topical azelaic acid in pregnant women.
The Finacea patient leaflet says that if someone is pregnant or breastfeeding, their doctor will decide whether they can use it. The Skinoren leaflet advises asking a doctor or pharmacist if pregnant, breastfeeding, possibly pregnant or planning a pregnancy. Ask the prescriber or midwife before starting or continuing either medicine; do not rely on general skincare advice for an individual decision.
When should you stop and speak to a clinician?
Stop using the medicine and contact the prescriber or pharmacist if irritation is persistent or painful, symptoms worsen, or you develop a rash or swelling. Seek an assessment if you are unsure the symptoms are rosacea, if they persist, or if the treatment plan is not helping as expected.
- Contact a GP or prescriber about persistent facial redness, inflammatory bumps, or a change in symptoms.
- Ask a pharmacist or prescriber about burning, dryness or other local reactions that concern you.
- Seek urgent GP or NHS 111 advice for a painful or red eye, blurred vision, light sensitivity or a gritty eye, as advised by the NHS rosacea guidance.
Frequently asked questions
Does azelaic acid really help with rosacea?
Evidence for azelaic acid is strongest for papulopustular rosacea, which includes inflammatory bumps and pustules. Azelaic acid 15% gel can help some people with this presentation, and UK Finacea is licensed for it. Trials also measured erythema, but do not show that treatment will stop flushing or remove visible vessels. A prescriber can check whether the symptoms fit the evidence and product licence.
How long do you use azelaic acid for rosacea?
Follow the duration set by the prescriber and the dispensed product information. The Finacea SmPC says a distinct improvement generally becomes apparent after four weeks. It advises considering another option if there is no improvement after two months or rosacea worsens. Use these timings to review progress with the prescriber; they do not guarantee a response on that schedule.
What are the downsides of azelaic acid?
With Finacea gel, application-site burning, pain and itching are listed as very common, meaning at least one in ten in the product information frequency bands. Dryness is listed as common. Skinoren cream has its own reaction profile. Burning that persists, a rash, swelling or worsening symptoms deserves advice from the prescriber or pharmacist.
What is the difference between azelaic acid 15% and 20%?
The same percentage does not make two medicines interchangeable. UK Finacea is a 15% gel licensed for papulopustular rosacea. UK Skinoren is a 20% cream licensed for acne vulgaris. Their formulations, licences and evidence differ. A prescriber should decide whether either named medicine fits the diagnosis and explain the directions for the specific product supplied.
Is azelaic acid safe during early pregnancy?
The Finacea and Skinoren product information says there are no adequate, well-controlled studies of topical azelaic acid in pregnant women and advises caution when prescribing. Their leaflets direct pregnant or breastfeeding patients to ask a doctor or pharmacist. That wording does not establish a universal safety verdict. Speak with the prescriber or midwife before starting or continuing a medicine.
Can azelaic acid make rosacea worse?
It can cause local reactions such as burning, itching, dryness or redness, which may make the face feel worse. The Finacea information says to avoid other topical medicines and skincare products that can irritate during treatment. If symptoms intensify, treatment becomes painful, or a rash or swelling develops, stop and contact the prescriber or pharmacist for advice.
How we wrote this
We checked the UK product information for Finacea and Skinoren, NHS, BAD and PCDS rosacea guidance, and PubMed abstracts of randomised trials and systematic reviews. We kept each trial's population, comparator and duration beside its result. Most studies enrolled people with papulopustular rosacea, so evidence for flushing or redness alone is limited, and none of these sources can predict an individual response.
This is general information, not medical advice; a GP, pharmacist or dermatologist can advise on your skin. Last reviewed 19 October 2026. Corrections: support@buytretinoin.org
