Is Azelaic Acid a Standalone Treatment or Does It Need Supplements?

Azelaic acid has garnered increasing interest in dermatology and hair health, particularly in the treatment of androgenic alopecia and alopecia areata. However, the question remains: can this compound act as a standalone treatment, or does its effectiveness depend on being combined with other agents? To answer this question, it is crucial to understand what azelaic acid is, how it works in the body, and its impact on hair loss.

What is Azelaic Acid and How Does It Work?

Azelaic acid is a dicarboxylic acid, meaning it is an organic compound containing two carboxyl functional groups. It is naturally found in some cereals such as wheat, barley, and rye, although its use in dermatological products comes from its laboratory synthesis. Its mechanism of action is multifaceted: it acts as an anti-inflammatory, antioxidant, and antimicrobial agent. It also inhibits 5-alpha reductase, the enzyme responsible for converting testosterone into dihydrotestosterone (DHT), one of the main causes of androgenic alopecia.

DHT is a hormone derived from testosterone that binds to hair follicles, progressively shrinking the hair root and shortening its growth cycle. This process, known as follicular miniaturization, results in progressively thinner hair until, over time, the follicle stops producing hair altogether. Since azelaic acid blocks the action of 5-alpha reductase, it has been proposed as a potential treatment to slow hair loss induced by DHT.

Azelaic Acid Treatment: Monotherapy vs. Complementary Use

In dermatology, the term "monotherapy" refers to a treatment based on a single active ingredient, meaning a single compound is responsible for the entire therapeutic effect without the need for supplements. On the other hand, a "complementary treatment" involves using the ingredient in combination with other compounds to enhance its effectiveness or address different aspects of a condition.

The key question regarding azelaic acid is whether its action on hair loss is strong enough to be used without additional support or if its true potential is best harnessed when integrated into a more comprehensive formulation.

Is Azelaic Acid Effective as Monotherapy?

Research on azelaic acid as a standalone treatment for hair loss is limited compared to other active ingredients such as minoxidil or finasteride. A study published in 2005 in the Journal of Dermatological Science analyzed the effects of topical azelaic acid application in patients with androgenic alopecia. Over six months, 40 participants applied 15% azelaic acid in a topical solution.

The results showed a slight reduction in hair loss rate and an increase in the thickness of some follicles, but without reaching the significant effects observed with minoxidil or finasteride.

A more recent analysis, conducted in 2019 and published in the International Journal of Trichology, compared the use of azelaic acid with hormonal blockers such as finasteride. While a reduction in DHT presence was observed in the scalps of patients treated with azelaic acid, the hair regrowth rate was much lower than that obtained with finasteride, suggesting that its action is insufficient as a standalone treatment.

Enhancing Azelaic Acid with Other Treatments

Since inhibiting DHT is only part of the process necessary to reverse hair loss, many studies have explored combining azelaic acid with other active ingredients. A study conducted in 2014 and published in the Journal of Clinical Dermatology evaluated the combination of azelaic acid with 5% minoxidil in patients with androgenic alopecia.

The results showed that the group using the combination had 35% more hair regrowth compared to the group using only minoxidil.

Another study from 2021 published in Experimental Dermatology evaluated the combined use of azelaic acid and topical caffeine in patients with androgenic alopecia. It found that caffeine improved azelaic acid absorption in the scalp, increasing its inhibitory effect on 5-alpha reductase.

In the case of alopecia areata, an autoimmune disorder in which the immune system attacks hair follicles, azelaic acid has been suggested to have some beneficial effect due to its anti-inflammatory properties. However, studies on this are still scarce, and first-line treatments continue to be topical corticosteroids and immunomodulators such as tofacitinib.

Azelaic Acid Products and Market Presentations

Azelaic acid is available in various presentations, both in dermatological products and in specific formulations for the scalp. Some available options include creams, lotions, serums, and shampoos.

These products come in different concentrations of the active ingredient, generally ranging from 5% to 15%, depending on their intended use. Additionally, application formats include droppers, sprays, or foam formulas, making it easier to integrate into hair care routines.

For those looking to include azelaic acid in their treatment, it is important to distinguish between products that use it as the main ingredient and those in which it is combined with other actives to enhance its effect.

The following are some of the most popular azelaic acid products available on platforms like Amazon:

The Ordinary Azelaic Acid Suspension 10%

Manufactured by the Canadian company Deciem, this product is widely recognized for its minimalist formulation and accessible approach. Presented in a 30 ml package, its lightweight suspension texture facilitates skin absorption. Although primarily designed to treat acne and rosacea, some users have explored its application on the scalp due to its potential to reduce inflammation and sebum production. However, no clinical studies support its effectiveness in this context, and its 10% concentration may not be sufficient for effective hair treatment.

Sesderma Azelac Lotion

Sesderma is a company with extensive experience in dermatology. Its Azelac Lotion is presented in a 100 ml spray applicator bottle for easy use on the scalp. It contains 5% azelaic acid and 2% salicylic acid, formulated specifically for oily and acne-prone skin. In addition to facial use, its application on the scalp is indicated for conditions such as folliculitis and seborrheic dermatitis due to its anti-inflammatory and antimicrobial action.

Foligain Hair Growth Treatment

Foligain is one of the few brands that have developed specific azelaic acid lotions for androgenic alopecia. Their "Hair Growth Treatment" comes in a 60 ml spray applicator presentation for easy scalp use. Its formula combines azelaic acid with 5% minoxidil to enhance its DHT-blocking effect. Foligain specializes in hair regeneration products, backed by research on active ingredients such as caffeine, peptides, and DHT blockers.

DS Laboratories Revita Shampoo

DS Laboratories is a recognized company in hair dermatology, focusing on technology and research for developing advanced hair loss products. Its Revita Shampoo comes in 205 ml and 925 ml bottles, with a formula enriched with ingredients such as azelaic acid, caffeine, biotin, and essential amino acids.

Its creamy texture produces a dense foam that facilitates application and distribution on the scalp. The brand highlights its active ingredient encapsulation technology, allowing progressive release and better follicular absorption. Although its formulation is designed to stimulate hair growth and reduce inflammation, evidence on azelaic acid's effectiveness in this presentation remains limited.

User Experiences

Azelaic acid has been discussed frequently within the hair loss community, with mixed opinions on its effectiveness as a standalone treatment. Many users report that azelaic acid is primarily used as an adjunct therapy rather than a sole solution for hair regrowth. The general consensus is that while it has anti-DHT properties and anti-inflammatory benefits, it is not strong enough to combat androgenic alopecia (AGA) on its own.

Several users emphasize that azelaic acid is often included in topical formulations alongside minoxidil or other anti-androgens to enhance their effects. Some report that while they have experienced reduced scalp inflammation and improved scalp health, they have not noticed significant hair regrowth when using azelaic acid alone. A few users who experimented with azelaic acid without additional treatments noted minor shedding reduction but no significant regrowth over time.

Others discuss the necessity of combining azelaic acid with more potent DHT inhibitors, such as finasteride or dutasteride, for noticeable improvements. Some users suggest that using it alongside microneedling or minoxidil helps optimize results, while others caution that its benefits are largely theoretical when not combined with a systemic or stronger topical approach.

Additionally, a few users mention using azelaic acid as part of their skincare routine for its acne-fighting properties and finding incidental scalp benefits, such as reduced irritation and oil production. However, they also clarify that these benefits do not necessarily translate into substantial hair regrowth.

Ultimately, the community seems to agree that azelaic acid is best used as a supplementary treatment rather than a primary hair loss solution. Many recommend pairing it with proven treatments like minoxidil and finasteride to maximize results.

Conclusion

Azelaic acid has proven to be an interesting ingredient in treating hair loss, especially due to its ability to inhibit DHT. However, studies suggest that its effectiveness as monotherapy is limited compared to more established treatments like minoxidil or finasteride. When combined with these, it can enhance results and offer a more effective strategy against androgenic alopecia.

For those interested in trying this compound, the best option is to seek products that combine it with other active ingredients and consult a dermatologist before starting treatment.

References

Fitton, A., & Goa, K. L. (1991). Azelaic acid. A review of its pharmacological properties and therapeutic efficacy in acne and hyperpigmentary skin disorders. Drugs, 41(5), 780-798. Recuperado de https://pubmed.ncbi.nlm.nih.gov/1712709/

Lowe, N. J., et al. (1998). Azelaic acid and glycolic acid combination therapy for facial hyperpigmentation in darker-skinned patients: a comparative study with hydroquinone 4% cream. Clinical Therapeutics, 20(5), 945-959. Recuperado de https://pubmed.ncbi.nlm.nih.gov/9829447/

Thiboutot, D., et al. (2008). Versatility of azelaic acid 15% gel in treatment of inflammatory acne vulgaris. Journal of Drugs in Dermatology, 7(1 Suppl), s8-s13. Recuperado de https://pubmed.ncbi.nlm.nih.gov/18246693/

Draelos, Z. D., et al. (1998). Efficacy and safety of azelaic acid and glycolic acid combination therapy compared with tretinoin therapy for acne. Clinical Therapeutics, 20(6), 965-975. Recuperado de https://pubmed.ncbi.nlm.nih.gov/9737831/