Azelaic acid vs metronidazole for rosacea
Every row cites its source. Where a cell reflects our own reading of the evidence rather than an external source, the row says so.
The two classic topical rosacea prescriptions, compared on their own head-to-head trials and the systematic reviews.
| Aspect | Azelaic acid 15% gel | Metronidazole 0.75% | Source |
|---|---|---|---|
| Head-to-head trial | Superior: 72.7% vs 55.8% lesion reduction, 251 patients, 15 weeks; kept improving while metronidazole plateaued after week 8 | Inferior on lesions and erythema in that trial | source |
| Split-face trial (20% cream) | Equal lesion reduction, better physician global rating | Equal lesion reduction | source |
| Evidence certainty | High (Cochrane 2015; GRADE 2019) | Moderate in both assessments | source |
| 2023 meta-analysis | Better erythema severity, overall improvement and lesion counts than metronidazole 0.75% | Comparator | source |
| Tolerability | More adverse reactions: 19.4% vs 7.1% in the active-controlled trial; the only topical with a significant AE odds ratio in the 2025 NMA | Gentler on application | source |