AZELAIC ACID =-==-===-=== Does anyone have experience with Azelex yet? Looks interesting. Does it work? Side effects? How does it compare to other topicals? Jerry Eisner Jerry D. Eisner MD ================== In the Philippines, 20% Azelaic acid has been available for several years under the name of Skinoren (Schering) and we have been using it for Acne vulgaris, melasma, ephelids and have gotten good results. It works as good as Kligman's formula for bleaching cream but we usually see results within 6 to 9 months of use. Kligman's works faster. Recently, we find that by incorporating a glycolic product to their regimen, 8 to 15% cream AM the bleaching effect can be achieved within three months. In the acne side, tretinoin still works better but later in the treatment phase where px's develop post inflam hyperpigmentation we incorporate Azelaic AM and Tret PM. Jonathan Yu, MD Skin & Cancer Foundation Makati, Philippines =================== Were you referring to the use of Skinoren with Glycolic acid? I use both Skinoren and Neostrata but have never used them together and would be interested to hear more about it - efficacy, side effects, regimens etc. I know that the accompanying information from Neostrata advises against using it with Tretinoin. J Sidhu MD Kota Kinabalu ============= I've used 20% Azelaic acid cream (Skinoren by Schering AG) for a couple of years and have had satisfactory results in patients with Acne and Melasma (though it does take 6-9 months in melasma as Dr Yu mentioned). The main adverse effect appears to be transient itching/stinging that around 80% of patients seem to get, which lasts from anything from a couple of minutes to a half hour. 10% discontinue usage because of this. I have also had good results in acne patients using combination therapy: Azelaic acid topically twice daily and oral Doxycycline (as compared to either of these alone). Azelaic acid used in the a.m and Isotretinoin gel (Isotrex 0.05% by Stiefel) p.m also seems to give better results in patients whose acne comprises mainly of comedones. These are clinical observations and I do not have any data to back these up. Hope that they're of some help. J Sidhu MD Kota Kinabalu ============= I suggest using minocycline 100 mg OD vs doxycycline which we find a very potent photosensitizing agent Jonathan Yu, MD Skin & Cancer Foundation Makati, Philippines =================== I use Neostrata also. In melasma patients we do a glycolic peel 20% or sometimes the 70 % for 3 mins more or less. After that we start them on Glycolic Face Cream Neostrata compounded with Azelaic 10gm/5gm at PM. The glycolic I think enhances the absorption of the azelaic bec of the decrease cohesiveness of the Stratum corneum cells. Sometimes we use the Neostrata enhanced gel 15% leave for 15 mins OD rinse and azelaic BID to treat melasma with very good results. Side effects are the itchiness and stinging but we minimize this by telling the patients to apply azelaic acid OD for 2 weeks then BID as maintenance. Sometimes to minimize the itchiness/stinging we add desonide cream 2.5 gms to 10 gms azelaic acid. Jonathan Yu, MD Skin & Cancer Foundation Makati, Philippines =================== I have some experience in using both glycolic acid and retinA. Some believe they have two different receptors in cell,therefore it does increase the cell turnover quite fast and very few patients can tolerate burning and scaling effect although they may tolerate either alone quite well. I have very good results with using combination of hydroquinon and glycoic acid(glytone,skin bleaching solution) even in patients(type 4 skin) fail in laser. ALSON WONG MRCP DIP DERM HONG KONG ========= I recently had a female teenage acne patient develop marked blotchy hypopigmentation while on Azelaic acid for acne for only one month. She also works as a lifeguard and has developed a dark tan in the past several weeks. Has anyone seen similar problems. Hypopigmenatation has been reported with this drug in patients with darker skin. Are people on the list warning patients regarding sun exposure while on this drug? Mike Crowe, M.D. ---------------- Maybe our European colleagues can comment on the use of Azelex as a depigmenting agent. I have a foggy memory of an A.A.D. meeting over ten years ago where possibly the Italian contingent was recommending its use for "senile lentigo and lentigo maligna" and Bernie clones went through the roof. I have given the cream to some patients instead of hydroquinone. 2 stopped due to irritation, even though they mixed in with Desowen Lotion for the first several weeks. I will report any positive responses. Diane Thaler ------------ Sorry, at least I can't. The only approved cream for depigmentation in Germany consists of hydrocortisone 1%, hydroquinone 5% and tretinoin .1% (aka Kligman's mix, if I remember correctly). I personally don't even use acelaic acid in acne, because it itches in most patients and is rather unconvincing in its effects. Hans Juergen Kammler Jena, Germany, Europe --------------------- I have a patient with stubborn perioral hyperpigmentation which I have treated with Melanex and 0.025% Retina-A for about two years now, with about a 70% improvement. Adding Azalex, while initially irritating, after two months, has given an additional 20% improvement. Allergan-Herbert has monographs available on this off-label usage. Also, some months ago, here, a dermatologist in the Phillipines related good experiences in using it for hyperpigmentation, which influenced me to try it perhaps earlier than I otherwise would have. BTW, while I sometimes agree with the anti-managed care discussion here, for the most part, my patients in the staff model HMO I work for get good care. And so do I. Michael Fetterman ----------------- I use Azelaic acid quite frequently for acne as well as for melasma, often in combination with topical Isotretinoin. I've not seen any photosensitivity with azelaic acid when used alone and I do not routinely warn patients of excessive sun exposure when using it (unless they are also using Isotrex). Azelaic acid does cause quite noticeble skin irritation in some patients necessitating discontinuation in about 10%. I've not seen any blotchy hypopigmentation when used in acne though. Did the patient complain about any irritation when using the cream and could the hypopigmentation have been post-inflammatory (i.e as a direct result of the inflammation or irritation caused by the azelaic acid rather than its bleaching effect)? I believe that Azelaic acid has been used quite extensively in the Phillipines. Perhaps Dr Jonathan Yu in Makati would like to comment? J S Sidhu Kota Kinabalu, Malaysia ----------------------- In the Philippines Azelaic Acid has been around for several years under the brand name Skinoren by Schering AG and we have been using it for Fitzpatrick Type II, III to V skin with no blotchy hypopigmentation noted. Its indication for use is for acne and melasma. BTW what is her skin type? One could do KOH scrappings of her hypopigmented lesion to rule out a fungal infection. We had several divers who had hypopigmentation secondary to a T. versicolor, uncommon in the face but we still see some of them. Irritancy to the drug seems to occur in 20% of our patients but we gradually break them in. We advise them to apply at bedtime for two weeks then BID there after. Lately we reformulated Azelaic acid into a gel base which is less irritating. Not available commercially, just doing it in our lab. Regarding sun exposure, I don't recall any problem to this but we usually don't place patients solely on Azelaic acid to treat acne bec it is not as effective as tretinoin. Because of our use of tret we advise the patients to avoid the sun or to use sunblocks. When we use azelaic acid to treat melasma or hyperpigmentation we still advise patients to avoid the sun for obvious reasons. Jonathan Yu, MD --------------- ------ 9.9.96