Trrarmem ( 1989).

2, I I - I5
Jounml of Drrtno~ok~gicol 0 Journal of Dermatological Treatment. 1989

Azelaic acid: pharmacology, toxicology and mechanism of action in acne

A Mayer-da-Silva
Univrrsily of Lisbon, Porrugal

Introduction

Azelaic acid (1.7-heptadicarboxylic acid, AA, shorter-time penetration after tape-stripping of the skin.’*
COOH-(CH,),-COOH) is a naturally occurring However, the percutaneous absorption in man seems to
saturated straight chained C,-dicarboxylic acid with a be very low (Schering AG. Berlin, personal communica-
molecular weight of 188.22. Azelaic acid (AA) can be tion).
prepared by disruptive oxidative processes of oleic acid’
and also produced by fermentative actions of different
J Dermatolog Treat Downloaded from informahealthcare.com by Kainan University on 04/04/15

micro-organisms on unsaturated fatty acids.’ Topical AA Mechanisms of action in acne

has proven therapeutic efficacy in acne,’-’’ and several
reports confirm AA as a potent drug for the treatment of
hyperpigmentary disorders such as chloasma, melasma,
post-inflammatory melan~derrna,”-’~and lentigo
maligna m e I a n ~ m a . ’ ~However,
-’~ the exact basis for its
mode of action is still unknown.
This article reviews the pharmacology and toxicology
of AA. as well as its mechanism of action in acne.
For personal use only.
Acne is a disease of the ‘sebaceous’ follicle (Figure 1). The
disease afflicts a high proportion of the population, at a
very sensitive and socially active period of life. The
clinical importance of the disease comes out of its
potential to produce the social and cosmetic problems.
While acne is often mild, in some cases it results in
significant scars. The evolution of acne is under hormonal
control, but several additional factors are obviously

important.
Pharmacology The pathophysiology of acne includes several well-
known processes including an increase in sebum produc-
AA has been administered as a pure compound to tion, follicular hyperkeratosis and perifollicular
humans orally, and as sodium salts by intravenous and inflammation resulting from microbial enzymatic
intralymphatic infusion. It has also been incorporated in activity.
cream preparations for topical use.
After oral administration to healthy individuals,” 60%
of AA is excreted unchanged in the urine during the first
12 hours, independent of the dose administered. At a high
dose (0.5 g) only a few milligrams of AA can be recovered
from urine collected during the subsequent 12 hours. AA
is not excreted in a conjugated form and does not induce
changes in urine pH, glucose or ketone bodies. Peak
serum levels are reached after 2 hours of oral administra-
tion; after 8 hours levels are negligible. AA is not
detectable in faeces.
The fate and distribution of unexcreted AA has been
studied in rats. Radio-labelled AA can be detected in all
body tissues, with highest concentrations found in the
liver, lung and kidneys 12 hours after oral administration.
The level of radioactivity then slowly decreases in all
organs, with the exception of adipose tissue, in which the
levels increase up to 96 hours. In tissue lipids, the
radioactivity was localized mainly in the fatty acid
portion of the triglycerides and phospholipids. These
findings strongly suggest that AA undergoes metabolic
transformation via p-oxidation, producing malonyl CoA
and acetyl CoA (Acetyl CoA enters the Krebs cycle and
malonyl CoA is a precursor in fatty acids and cholesterol
biosynthesis).
After topical application, the drug penetrates the
human epidermis in a time-dependent fashion, with

Figure 1 Electron micrograph of the acro-infundibular epithelium

Correspondence: Dr A Mayer-da-Silva, Department of Dermatology. (granular and horny layers) in an acne patient. Note the horny cell
University of Lisbon, Hospital de Santa Maria, P 1699 Lisboa Codex, layers, containing abundant lipid droplets. Note also ‘the s i a ,
Portugal number and orientation of the kcratohyaline granules. ( X 9490)
 12 A MAYER-DA-SILVA
There is evidence that AA creams do produce beneficial
effects in acne,’-’’ although the mechanisms through
which the drug produces its beneficial action on acne are
not fully known. However, several mechanisms of drug
action have been investigated with the use of both in vivo
and in vitro systems.
AA does not appear to affect the sebum excretion rate
in patients with acne or seborrhoea or in patients with
normal skin.’’-” After 12 weeks of topical treatment, no
significant differences in sebum-excretion rates could be
detected by Gassmuller et on comparison of drug-
treated and placebo-treated sides of the face in the same
individuals. The placebo consisted of the basetream used
as a vehicle for the drug. The same authors found that AA
did not alter sebum composition, as measured by thin-
layer gas-chromatography analysis of sebum samples
extracted before and after treatment.
AA also does not exert any direct influence on the size
J Dermatolog Treat Downloaded from informahealthcare.com by Kainan University on 04/04/15
and numbers of the individual lobules of human se-
baceous glands. This conclusion is based upon a histo-
planimetric study conducted by Parry,” in which the
number and size of sebaceous glands in normal individ-
uals, as well as those with acne and seborrhoea were
measured before and after treatment with a cream
containing AA and with the cream base alone.
Several studies performed by our groupa-” lead us to
the conclusion that AA modulates epidermal differ-
entiation in vivo and has a marked anti-proliferative
For personal use only.
cytostatic effect on in vitro cultured keratinocytes. The
in vitro system used was a well-established model for
screening drugs and drug-related effects.” Rach et a]”
also found some modulating effects of AA on keratiniza-
tion, using an animal model. The influence of AA on
epidermal keratinization in vivo was evaluated by elect-
ron microscopy and immunocytochemistry on specimens
obtained from 24 subjects participating in a clinical
double-blind half-side placebo-controlled trial. The drug-
treated side was always compared with the placebo-
treated side. AA induced marked alterations in the
epidermis of both the follicular and interfollicular epider-
mis, affecting particularly the terminal phases of epider-
mal differentiation. The number and size of these
keratohyaline granules were decreased by AA, which also
induced enlargement of the rough endoplasmic reticulum,
swelling of the mitochondria, abnormal distribution of
the tonofilaments and intercellular oedema. In the acro-
infundibular areas the thickness of the horny layers was
markedly reduced, and several horny cells showed a wide
and irregular distribution of their cytoplasmic content.
Using immunocytochemistry, we were able to show that
the terminal phases of keratinization were dramatically
affected by AA, in that the filaggrin distribution in acne
and seborrhoeic skin returned to normal.
In vitro, AA inhibited DNA synthesis in cultured
keratinocytes in a concentration-dependent manner.
There was a 50% inhibition of DNA synthesis, as
measured by ’H-thymidine incorporation, with a concen-
tration of AA of 20 mmol/l. AA markedly reduced the
number of DNA-synthesizing cells at a concentration of
20-50 mmol/l, but in a concentration of 10 mmol/l AA
did not have any anti-proliferative action. The onset of
the anti-proliferative effect was very quick, and it reached
a maximum after 4 hours. The drug-induced effects were
reversible within 2 hours after discontinuation of AA
exposure. Thereafter a rebound effect was observed, with
progressive increase of ’H-thymidine incorporation and
I
autoradiographic labeling indices. This rebound effect
was due to a temporary augmentation of semi-
conservative DNA synthesis and was not caused by a
DNA repair mechanism itself.
AA also decreases protein synthesis of cultured
keratinocytes, particularly of the high-salt-soluble frac-
tions, the keratohyaline macro-aggregates and the non-
cross-linked fibrous proteins. In the cyostolic fractions
there was a decrease in the 95 K D and 36 K D proteins.
Electrophoresis demonstrates that the membrane pro-
teins are not affected.
These results clearly showed that AA does not inhibit
protein synthesis in general but exerts its action in a
selective manner which has not yet been completely
identified. Electron-microscopic analysis of the cultured
cells revealed mitochondrial damage (with swelling, pro-
gressive absence of the mitochondrial cristae and rarefac-
tion of the matrix) and enlargement of the rough endo-
plasmic reticulum in a dose- and time-dependent fashion.
After discontinuation of treatment, the keratinocytes
progressively recovered their normal structure. The body
of experiments performed by our group suggests that AA
acts on the keratinocytes by a cytostatic mode of action,
specifically inhibiting the synthesis of cytoplasmic pro-
teins related to the terminal differentiation process of the
epidermis (keratoyaline granules, filaggrin and non-
cross-linked proteins) and targeting mitochondria and
rough endoplasmic reticulum.
AA possesses bacteriostatic properties against a variety
of organisms, including Propionibacterium acnes,
Staphylococcus aureus and Staphylococcus epider-
midis.”-” Our electron-microscopic studies in acne-
bearing skin before and after treatment supports the
anti-microbial activity of AA. Comedones obtained
before AA treatment were always filled with abundant fat
droplets with varying electron density, horny material,
multitudes of bacteria and clusters of ovoid yeast spores
(Figure 2). In comedones obtained after treatment the
follicular channel still contained abundant fat droplets
and a little horny material, but the numbers of bacteria
and spores were dramatically decreased (Figure 3).
One potentially important factor in the pathogenesis of
acne is the stimulation of sebum production by and-
Figure 2 Electron micrograph of a follicular channel of an
untreated acne patient. Huge numbers of bacteria and P ovrrle (PO)
arc Ken. ( x 20.500)
 PHARMACOLOGY, TOXICOLOGY A N D MECHANISM OF ACTION
J Dermatolog Treat Downloaded from informahealthcare.com by Kainan University on 04/04/15
Figure 3 Electron micrograph of a follicular channel of an acne
patient after 3 months of AA topical treatment. After the treatment
the follicular channel is filled with fatty droplets and desquamative
horny cells, but bacteria and yeasts are rarely found. ( x 9430)
rogens, particularly by dihydrotestosterone. This hor-
mone represents the last step in the metabolic chain of the
androgens; it is produced in the skin by the enzymatic
degradation of testosterone by 5-a reductase.
For personal use only.
Stamadiadis et aY9showed that AA is a potent inhibitor of
5-a reductase. However, as sebum production is not
affected by AA, the true role of any reductase inhibition is
in doubt.
Toxicology
Toxicology studies indicate that AA is a remarkably safe
drug in both humans and animals. No hypo- or hyper-
pigmentation, allergic reactions or major skin alterations
have been reported after short- or long-term applications
of AA-containing creams on normal human skin. How-
ever, transitory irritative effects have occurred in a few
individuals. They consist of discrete erythema and/or fine
pityriasiform scales sometimes associated with mild burn-
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