Expert guide: Aesthetic & Cosmetology 2015 34 June 2015 June 2015 35 Multiple studies show that combina-tion therapy is more effective than single agents used alone. Different therapies acting at different stages of pigmentation can produce better clinical results than a single therapy acting at a single stage.The most used combination therapy for melasma has been the Kligman formula, which combines hydroqui-none 5%, tretinoin 0,1% and dexa-metasone 0,1%. More recently a new combination of hydroquinone 4%, tretinoin 0,05% and fluocinolo-ne 0,01% has been commercialised proving better than any other com-bination, with 77% of patients show-ing complete or almost complete clearing.Tip 4. Use chemical peels with care Superficial chemical peels are an at-greater improvement with minimal adverse effects.Tip 5. Use laser only in non-respond-ing cases The challenge of the use of lasers in patients with dark skin is to achieve effective treatment with minimal complications. We have to be con-servative, with low energy settings, appropriate wavelengths and cau-tious with the use of cooling tech-niques. The use of lasers should be restricted to cases unresponsive to topical therapy or chemical peels and an appropriate maintenance therapy should be selected to avoid relapse when treating melasma. If we decide to proceed with the use of laser devices one of the best op-tion is a Q Switch Nd: Yag laser. It is critical to use at least a SPF 30 sun-tractive option because of their few side effects and minimal recovery time. The burning sensation associ-ated with superficial chemical peels is mild, not requiring the use of topi-cal or local anesthetic. Nevertheless, these therapies require extensive experience in its use to prevent the development of irritant dermatitis. In patients with ethnic skin, irritant dermatitis can lead to postinflam-matory hypopigmentation or hyper-pigmentation.A clinical trial showed the safety and efficacy of glycolic acid peels on postinflammatory hyperpigmen-tation in dark skin individuals. The treatment consists in the application of a 2% hydroquinone/10% glycolic acid gel plus the application of six serial glycolic acid peels (68% maxi-mum concentration). This study demonstrated a more rapid and screen before and after the laser treatment and it is also advisable the use of hydroquinone and tretinoin during the treatment.Dr. Juan Aguiar is a certified plastic surgeon, member of the Internation-al Society of Aesthetic Plastic Sur-gery, the Spanish Society of Plastic and Reconstructive Surgery, and the Skin of Color Society.He received his training at Vall d’Hebron Hospital, one of the top institutions in Barcelona and com-pleted his cosmetic training in Bra-zil, Singapore and the USA. He has more than 10 years of experience in the field of cosmetic surgery and since 2014 he has been in charge of the department of plastic surgery at Hospital La Paz in Malabo, Equato-rial Guinea.Guinea