In terms of treatment response (PGA), azelaic acid is probably less effective than benzoyl peroxide (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.72 to 0.95 1 study, 351 participants), but there is probably little or no difference when comparing azelaic acid to tretinoin (RR 0.94, 95% CI 0.78 to 1.14 1 study, 289 participants) (both moderate‐quality evidence). The following results were measured at the end of treatment, which was mainly long‐term for the PGA outcome and mixed length (medium‐term mainly) for minor adverse events. We grouped outcome assessment into short‐term (less than or equal to 4 weeks), medium‐term (from 5 to 8 weeks), and long‐term treatment (more than 8 weeks). We assessed 26 studies as being at high risk of bias in at least one domain, but most domains were at low or unclear risk of bias. Study duration ranged from three months to three years. Treatment lasted over eight weeks in 59% of the studies. The vast majority of participants had mild to moderate acne, were aged between 12 to 30 years (range: 10 to 45 years), and were female. We included 49 trials (3880 reported participants) set in clinics, hospitals, research centres, and university settings in Europe, Asia, and the USA.
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