TABLE 1.

General treatment guidelines

FIRST-LINE THERAPY	SECOND-LINE THERAPY
Topicals with triple combination therapy (including hydroquinone, topical retinoids, topical steroids)	Chemical peels in combination with topicals Salicylic acid peels may help with concominant acne Studies show some data favoring glycolic acid peels
Topicals, such as zinc sulfate, arbutin, azelaic acid, kojic acid; some cosmeceuticals can be added as a second topical, but can be tried as monotherapy	Laser therapy Pay particular attention to skin type, laser fluence, and type Recent studies show benefits with Q-switched Nd:YAG
Should patients develop irritation/allergy to triple combination therapy, dual combinations can be used (either due to a retinoid dermatitis or hydroquinone sensitivity)