|Year : 2019 | Volume
| Issue : 4 | Page : 380-395
Striae distensae treatment review and update
Archana J Lokhande1, Venkataram Mysore2
1 Department Of Dermatology, ESIC PGIMSR, Model Hospital, Basaidarapur, New Delhi, India
2 Venkat Charmalaya Centre for Advanced Dermatology and Postgraduate Training, Bangalore, Karnataka, India
|Date of Web Publication||28-Jun-2019|
Venkat Charmalaya Centre for Advanced Dermatology and Postgraduate Training, 3437, 1 G Cross, 7 Main Subbanna Garden, Vijay Nagar, Bangalore - 560 040, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Striae distansae (SD) or stretch marks are very common, asymptomatic, skin condition frequently seen among females between 5 to 50 years of ages. It often causes cosmetic morbidity and psychological distress, particularly in women and in certain professions where physical appearances have significant importance. Of late, with the increasing emphasis on cosmetic management and awareness, patients approach dermatologists for stretch marks treatment. However, despite several advances, no fully effective treatment has emerged. Unfortunately, there is paucity of the strong evidence in the literature for the effective treatment of striae. A literature search using the terms 'striae distansae (SD or stretch marks' was carried out in the PubMed, Google Scholar and Medline databases. Only articles related to the treatment were considered and analysed for their data. Commonly cited treatments include topical treatments like tretinoin, glycolic acid, ascorbic acid and various lasers including (like) carbon dioxide, Er:YAG, diode, Q-switched Nd:YAG, pulse dye and excimer laser. Other devices like radiofrequency, phototherapy and therapies like platelet rich plasma, chemical peeling, microdermabrasion, needling, carboxytherapy and galvanopuncture have also been used with variable success. This article reviews all currently accepted modalities and their effectiveness in the treatment of stretch marks.
Keywords: Lasers, striae, treatment
|How to cite this article:|
Lokhande AJ, Mysore V. Striae distensae treatment review and update. Indian Dermatol Online J 2019;10:380-95
| Introduction|| |
Striae distensae (SD) commonly known as stretch marks are visible linear scars which develop in areas of dermal damage as a result of excessive stretching of the skin. They are twice as common in females and are reported in the age group of 5–50 years.
Striae are extremely common and often cause cosmetic morbidity and psychological distress, particularly in women and certain professions. Of late, with the increasing emphasis on cosmetic management and awareness; patients approach dermatologists for striae treatment. However, despite several advances, no fully effective treatment has emerged.
This article will evaluate the existing treatments and their efficacy and provide a concise review of available therapeutic modalities for SD.
Methods of search: A through search of the literature using the words 'striae distensae', striae rubra, striae alba and stretch marks was carried out in the PubMed, Google Scholar and Medline databases. Articles which focused on the treatment of SD were considered and analysed critically.
Striae generally develope in various physiological states such as pregnancy, growth spurt during puberty or rapid change in proportion of specific body regions such as in weight lifters, obese or weight loss.
They are also seen in pathological conditions with hypercortisolism like Cushing's syndrome and genetic disorders such as Marfan syndrome. SD sometimes may occur as a side effect related to drugs such as local or systemic corticosteroid therapy, and anti-retroviral protease inhibitors (indinavir).
The origin of SD is thus multifactorial and exact etiopathogenesis of SD still remains controversial. Primary pathology lays in altered dermal connective tissue framework involving components of extracellular matrix (ECM) namely fibrillin, elastin, fibronectin and collagen.,
In the initial stages, elastic fibres undergo elastolysis along with degranulation of mast cells. Affected tissue may also show low expression of collagen and fibronectin genes or high proportion of rigid cross-linked collagen, which makes the connective tissue prone to stress rupture.
Other factors like genetic predisposition, mechanical stress, hormones especially corticosteroids (both topical and systemic) also play an important role in causation.,
On histopathology, in initial stage (i.e., striae rubra (SR), the epidermis is almost normal and dermis is oedematous with perivascular lymphocytic cuffing suggestive of inflammation. As ageing of lesion occurs, i.e. striae alba (SA) epidermis becomes thin, atrophic with blunting of rete ridges and absence of skin appendages.
Early lesions of SD are smooth, raised, irritable and erythematous to bluish in colour, known as SR. As the lesion ages, it flattens, becomes pale and irregular with finely wrinkled surface known as SA; which is usually permanent.
Clinically SD appear as multiple, symmetric, well defined, irregularly linear, red to pale coloured (depending upon the stage) atrophic scars which follows the lines of cleavage and lies parallel to the skin surface.
The pubertal growth spurt induced SD are commonly seen after thelarche. They are present over thighs, buttocks and breasts in girls. In boys, they often develop over lumbosacral region and outer aspect of the thighs. Stretch marks of pregnancy, also known as striae gravidarum (SG); are commonly seen over abdomen, breast and thighs in third trimester. SG lesions are more common in young primigavida and are associated with higher weight gain in pregnancy, large for gestational age babies and increased risk of traumatic vaginal delivery.
Overall striae are generally benign in nature; rarely the bigger lesions may ulcerate or rupture if traumatised.
As explained earlier, multiple pathological changes occur in the dermal connective tissue components as lesions of SD progress from SR to SA stage. They are reflected macroscopically as altered texture, strength and colour of the skin.
The dermal collagen bundles get thinned out with altered orientation of fibres.
Diagnosis of striae is often clinical and straight forward without any need of specific investigation.
Striae, while otherwise being harmless, are frequent cause of cosmetic concern or disfigurement leading to distress in the affected individuals especially females. With increasing preference for outdoor activities such as gym and swimming; apparels which reveal part of the riff, midriff or thighs, in the modern women, treatment of striae has become a necessity in many patients.
In adolescents, SD associated with pubertal growth spurt becomes less conspicuous with time and has excellent prognosis as compared to other SD. Other SD, like SG tends to improve to some extent after delivery. Even corticosteroid-induced striae may disappear or become inconspicuous after withdrawal of offending steroid. Hence counselling is an important part of initial management in all cases.
Multiple treatment options have been reported with varying success, from numerous topicals to lasers and energy based devices. However, most available publications are small studies, case reports and very few case-controlled double blind trials. Only a few of these are proven and have evidence, whereas many others are hyped by product manufacturers.
In view of this, it is very important to understand the basis of different therapeutic options and to choose the right modality and ensure proper counselling to the patients to optimise treatment outcome.
[Box 1] enumerates the targets of different therapeutic modalities used in SD.,
General measures for prevention of striae
Development of stretch marks may be prevented by avoidance of brisk weight gain or loss; particularly in high-risk groups, e.g., adolescents, athletes and pregnant women.
Dietary modifications and exercise plan were thought to be important for reduction of SD in earlier days. A study conducted by Schwingel et al. has failed to demonstrate effect of any weight loss programme diet and any type of exercise on SD.
The various topical therapeutic agents used for SD are enlisted in [Table 1]. Tretinoin and retinoic acid have been found to be useful in several studies., In early SD, it is believed to act by stimulation of fibroblasts leading to increase tissue collagen levels. Studies have found it to be effective in SR also, though transient erythema and scaling were most common side effects.,
Hyaluronic acid is also found to be effective in SD as it increases collagen production. Other agents used with varying success are trofolastin (Centella asiatica), silicone, glycolic acid, ascorbic acid, alphasria, cocoa butter, olive oil, almond oil, chamomile, coconut oil and bio-oil.
In one study, pirfenidone which is a small synthetic non-peptide having immuno-modulatory as well as anti-inflammatory properties has also been used. It can also modulate collagenase, fibroblastic activity and cytokines in the wound healing process thus found to be effective in SD.
In spite of multiple topical therapies being available for treatment of SD, there are limited numbers of evidence-based scientific studies documenting the efficacy of these agents. The reported efficacy is modest and the drugs need to be used for prolonged periods of time. Therefore, efficacy of topicals in prevention and treatment of SD is questionable.
In the recent years, there has been a dramatic increase in minimally invasive non-surgical skin rejuvenation procedures and technologies which offer minimal downtime leading to increased patient compliance. The basic principle on which these therapies are based is induction of controlled inflammation in dermis which results in stimulation of neocollagenesis by recruitment of fibroblast. To be effective in SD, in addition to neocollagenesis, these modalities should also reduce erythema in SR and improve pigmentation in SA. Different procedural therapies used for SD are enlisted in [Table 2].
| Lasers|| |
Lasers are the light energy based devices which deliver coherent, cohesive and monochromatic light energy to the skin by acting on specific tissue chromophore. The lasers target different chromophores such as water, haemoglobin and melanin and thus improve overall appearance of SD by increasing collagen production, decreasing vascularity (especially in SR) and by increasing melanin pigmentation., Both ablative and non-ablative lasers have been tried with varying success in striae management.
Ablative lasers of wavelength more than 1000 nm are readily absorbed by tissue water, results in cell vaporisation, tissue heating and remodelling. The commonly used ablative lasers for SD are CO2 (10,600 nm) and Er:YAG (2940 nm).
However, ablative lasers are associated with severe erythema, post-procedure pigmentation and prolonged downtime.
In an attempt to combat these shortcomings, the concept of fractional photothermolysis was introduced. In this, the laser beam creates non-contiguous areas of thermal damage having controlled width, depth and density with sparing of adjacent epidermis termed 'microthermal tissue zones'. Within these areas, localised epidermal necrosis occurs alongside collagen denaturation. Ultimately, the necrotic debris is expelled and neocollagenesis occurs. All this leads to rapid dermal collagen remodelling with sparing of intermittent epidermis, ultimately leading to improvement in these atrophic dermal scars. These devices are thus associated with minimal downtime and are dealt with more detail below.
Fractional CO2 10,064 nm (Fr CO2)
This laser stimulates fibroblast activity, induces dermal tissue remodelling and thus has been successfully used for laser resurfacing of SD. The clinical improvement was also reflected histopathologically as increase in thickness of epidermis and dermis as well as higher immunoreactivity of procollagen type 1. However, multiple sessions were needed.
The use of this laser is associated with erythema, post-treatment pain, crust formation and pigmentary dyschromia which may be a cause of concern in the darker skin types IV and VI., Shin et al. in his study proposed the positive effect of succinylated atelocollagen with fractional resurfacing CO2 laser on SD. In another study, monthly fractional CO2 laser sessions were compared with topical therapy regimen comprising 10% glycolic acid + 0.05% tretinoin cream at every night. The former was found to reduce the mean surface area of SD more effectively as compared to the topical therapy. Fractional CO2 laser was more effective in reduction of mature SD than in SR. Treatment outcome of fractional CO2 laser was found to be augmented when used in combination with pulsed dye laser (PDL). In a study comparing ablative laser (fractional CO2) with non-ablative lasers (1540 Er glass laser) in SD, both were found equally effective, but the latter was more patient friendly and better tolerated.
Fractional Er:YAG laser
Variable square pulse Er:YAG laser has been used for resurfacing of the SD. Wanitphakdeedecha et al. has shown efficacy of lower fluence in volumetric reduction of striae. In another comparative study with variable square pulse Er:YAG and Nd:YAG laser investigators have refuted use of either lasers in management of SA. In comparative study of PDL and fractional Er:YAG laser, both were found to be equally effective, though Er:YAG laser was preferred by patients. The laser has also been found effective in ethnic skin especially skin type IV–VI in terms of efficient fractional non-ablative photothermolysis as well as minimal side effect profile. On an average 6–8 sittings at 4 weekly intervals are required to obtain sustainable improvement in dimensions, texture and pigmentation of SD.
| Non-Ablative Lasers|| |
Erbium glass (Er glass 1540 nm) laser
Erbium glass laser has also been used for fractional photothermolysis. Generally, repetitive treatments (4–6 sessions) are required at 4–6 weeks interval.,, The laser (1550 nm) has shown to reduce dimensions of SD with improved elasticity, colour and skin texture; when used by multiple investigators in different striae like SG, breast striae post-augmentation surgery and steroid-induced striae. Stotland et al. has reported overall improvement in dimensions of SD independent of age, gender and skin phototype with the use of 1550 nm, erbium-doped fibre laser; but lesser improvement in dyschromia and texture of striae. Most common adverse events were transient pain, post-treatment erythema, oedema and dyschromia. In another study by Wang et al. two different wavelengths 1540 and 1410 nm of lasers were compared; both were found efficient in SD reduction without any significant difference between the two. Tretti and Lavagno has used a different frequency 1565 nm (Resur FX) laser in stretch marks which demonstrated improved pigmentation, volume and textural appearance of SD.
Pulsed dye laser
Initial stages of SR are marked by erythema due to presence of dilated blood vessels and the haemoglobin in these microvasculature acts as a chromophore for PDL, making it a good treatment candidate for SD management. McDaniel and colleagues have used PDL at different energy densities for SD and found improvement in appearance of the striae with higher energy. They concluded it was due to increased dermal elastin and collagen production. In other studies there was limited improvement noted in SA as compared to SR, the overall improvement was more in colour. Study by Nehal et al. had noticed only mild subjective improvement in texture of mature SD with the use of PDL but it failed to show the same changes histopathologically. In darker skin types (IV–VI) melanin also competes with haemoglobin as a target for PDL, thus the use of this laser increases the risk of pigmentation post-therapy. There are multiple comparative studies performed with PDL versus intense pulsed light (IPL), fractional CO2 and Er:YAG lasers; which concluded that it is better than IPL but not superior to fractional ablative lasers. In one study when fractional CO2 and PDL were used together, it was found that the combination of two lasers is superior to the single modality.
308 nm Excimer laser
Excimer laser has a wavelength in the narrow-band ultraviolet B (NBUVB) light spectrum. As compared to other lasers, excimer laser specifically acts by increasing pigmentation of SA and hence are thought to be useful in striae atrophicans. A study conducted by Goldberg et al. on the use of excimer laser for SA found cosmetically significant pigmentation of SA with repetitive sessions. In a further comparative study (2005), the same author has investigated the use of UVB light therapy and the excimer laser in SD and found repigmentation of SD with both the light as well as laser. On histopathology and electron microscopic study, excimer laser was found to cause hypertrophy and hyperplasia of melanocytes leading to increase melanin pigmentation without any improvement in dermal atrophic scarring. Other studies have also confirmed this finding in SA as well as in hypo-pigmented scars. However, in study conducted by Ostovari et al. use of excimer laser showed very weak results along with splaying of the pigment to surrounding normal skin as a major side effect. All the reported changes are short term and not permanent in nature, and hence multiple maintenance treatments are necessary.,
Nd:YAG 1064 nm
The neodymium-doped yttrium aluminium garnet has affinity for all the chromphores relevant to SD, viz. Hb, water and melanin. Goldman et al. have used it successfully for SR. In another study by Elsaie with the use of two different fluences, investigators reported significant improvement in SA at higher energy of 100 J/cm2, while SR responded better with 75 J/cm2 (four sessions). An Egyptian study by El-Ramly et al. failed to show any statistically significant clinical improvement in SD after four sittings of Nd:YAG laser.
The 1450-nm diode laser has been shown to increase dermal collagen but it has been reported only once in the literature for the management of SD. In a trial by Tay, three laser sessions with increasing energy failed to show any improvements in SD but there were high rates of adverse events like pigmentary dyschromia and erythema noted.
| Copper-Bromide Laser|| |
Copper-bromide laser of wavelength 577 nm is more selective for haemoglobin than PDL and thus was also tried for SD management. Longo et al. have used it with fluence of 4–8 J/cm2 in 15 patients of striae and noted moderate improvement in the lesions but the results were inconsistent. They observed transudation, crusting and scabbing as adverse effects.
Even though the lasers are thought to have role in the SD, body's normal healing process also goes hand in hand with it, which might be contributing to the results of the lasers.
Summary of findings of laser
Although a variety of lasers have been used in SD, results are inconsistent. Fractional ablative and non-ablative lasers perhaps have shown the maximum beneficial outcome.
The non-ablative and fractional microneedle radiofrequency (MNRF) devices have been recently used for tightening of the skin with significant efficacy and safety profile. Higher-energy fluences generated by radiofrequency (RF) current by coupling method are delivered to the dermis and subcutaneous tissue without causing damage to the epidermis. This transmitted electrical energy upon reacting with the skin's impedance is converted to homogenously distribute thermal energy, which in turn leads to stimulation of fibroblasts with contraction and denaturation of fibrillar collagen structure. All these changes promote neocollagenosis, neoelastogenesis and changes in ECM. All types of RF devices like monopolar, bipolar, tripolar and multipolar have been successfully used in treatment of SD. A study conducted by Montesi et al., has shown that multiple sessions of bipolar RF are highly effective in SD management showing improvement on clinical, histopathology and immunohistochemistry. Sometimes with higher fluences, erythematous rashes, ecchymosis or occasional blistering are observed. Average number of sittings required in RF is 3–6, performed at 4 weekly intervals. Investigators have used this technology in conjunction with other modalities like PDL, autologous PRP, pulsed magnetic fields, infrared (IR) light therapy as well as topical like retinoic acid and found it to be more efficacious than RF alone in management of SD. The fractional method of delivering heat energy to the tissue has also been used in RF devices for better penetration of thermal energy to the target area with safety. Pongsrihadulchai et al. have found statistically significant reduction in dimensions and total surface area of SD with nano-fractional RF. These changes were reflected histopathologically by increase in average mean number of collagen and elastin bundles. A fractional ablative micro-plasma RF roller device (by Alma lasers, Israel) for SD was used by Mishra et al. in five patients; the study concluded that there was improvement in the appearance of abdomen striae with this newer device.
Platelet rich plasma
Platelet rich plasma (PRP) is a concentrated solution of plasma containing various growth factors and protein, injected intra dermally and acts by augmenting dermal elasticity by stimulation of ECM and inducing synthesis of new collagen. It has been used alone as well as in combination with RF,, carboxytherapy, ultrasonography and found to have synergistic effect in the treatment of SD. In a split comparative study of PRP versus carboxytherapy done once a month in 20 patients of SA by Hodeib et al. both were found effective; with carboxytherapy being superior to PRP. Gamil et al. in a comparative study of PRP versus 0.1% tretinoin cream found it to be more effective than tretinoin for SA. However, this is a recent modality and the results need to be confirmed in larger studies.
Microneedling therapy or percutaneous collagen induction therapy
In this minimally invasive method, small needles are used to create micro channels extending to the papillary dermis. This induced inflammation stimulates dermal wound healing by increasing collagen and elastin synthesis. Aust et al. and Park et al. have independently used this therapy and reported marked improvements in appearance and texture of SD. Khater et al. compared microneedling with fractional CO2 laser, while Nasser et al. used microneedling versus microdermabrasion (MDA) with sonophoresis; both studies found microneedling/percutaneous collagen induction therapy more effective than the other two. Averages three sessions of microneedling treatment at 4 weekly intervals are needed.
The procedure of micro resurfacing uses aluminium oxide crystals which causes mechanical ablation of damaged skin leading to inflammatory cascade. Even with a single treatment session there is an elevation of transcription factors, cytokines [tumour necrosis factor-α (TNF-α), interleukin-β (IL-β)], matrix metalloproteinases (MMPs)-1, 3, 8 and increased type 1 procollagen formation. A study done by Abdel-Latif et al. showed good-to-excellent response in 20 subjects of SR with monthly sessions of MDA for 5 months. The histochemical analysis showed upregulation of type I procollagen mRNA. Mahuzier states that 10–20 sessions of MDA done at monthly interval lead to epidermal thickening as well as more collagen and elastic fibres in the dermis. The procedure is said to be having no efficacy in hypodermic rupture and it may cause post-inflammatory pigmentary changes as an adverse effect. A comparative study of MDA versus topical tretinoin in early SD by Hexsel et al. showed both modalities to be equally efficacious. However, MDA is associated with lesser side effects and better patient compliance.
Intense pulsed light
IPL is a type of non-laser visible light-based device which uses high intensity, non-coherent, filtered flash lamp, with a broadband frequency spectrum of around 500–1200 nm. Studies investigating use of IPL 2–4 weeks apart from five sessions in SD have found significantly increased amide1 and beta sheets along with dermal collagen on histopathology and synchrotron IR microspectroscopy., In a comparative study by Mausin et al. on two different IPL wavelengths, 590 nm was found to be more effective in reducing erythema and dimensions of SD than 695 nm. However, in comparative studies of IPL versus lasers like fractional CO2 and PDL, the lasers proved to be superior.
| Miscellaneous Light Based Therapies (Other Than Lasers) for SD|| |
1. UVB (296–315 nm) and UVA1 (360, 370 nm)
A combined UVB and UVA1 wavelength emitting high-intensity light device model with wavelength peaks at 313, 360 and 420 nm was used in SD by Sadick et al.
In this study greater than 51% improvement in SA pigmentation was reported after weekly (maximum 10 weeks) phototherapy sessions in all nine study participants. Transient hyperpigmentation of striae was seen in almost half the subjects as an adverse event. On biopsy it failed to show any effect on collagen remodelling, thus limiting its efficacy only for repigmentation of SA.
2. IR light
Thermal energy from IR light is known to cause collagen remodelling and neocollagenesis effects. Trelles et al. in his study used IR device to deliver high fluences with high frequency stacked pulses in 10 patients and observed objective improvement in SD did not match visual observations where both physician and patients did not appreciate much clinical benefit.
Applications of chemical agents are thought to induce inflammatory response, with subsequent neocollagenosis. The most commonly used agents are trichloroacetic acid, retinoic acid and glycolic acid (GCA)., Post-inflammatory pigmentary changes and mild irritation are the most common adverse events.
Chemical peeling is a cost effective option for treating wider surface area of SD.
In this therapy low level direct micro current is applied to the body with the help of needles to reduce the oxidative injury with subsequent collagen production. Its use in SA was investigated by Bitencourt et al. which demonstrated substantial clinical improvements in 32 SD patients after 10 sessions. Ferreira et al. has compared galvanopuncture versus dermabrasion; he found both treatments showed improvement in SD but the difference was statistically insignificant.
In this procedure, CO2 gas is injected subcutaneously at the depth of 5–6 mm in striae, at weekly interval for 3–12 sessions (depending upon the age of striae). This stimulates blood circulation and increases the release of oxygen by means of oxyhaemoglobin. It also activates the synthesis of collagenase, elastin and hyaluronic acid by stimulation of fibroblast function.
Study performed by Podgórna et al. demonstrated increase skin elasticity, decrease in SD dimensions and improved aesthetic appearance on cutometric assessment post carboxytherapy. The therapy is associated with moderate pain or discomfort and haematoma formation. However, this modality is controversial and cannot be therefore recommended as a routine treatment.
The above review suggests that while multiple modalities have been documented to be of use, no single treatment is fully satisfactory [Table 3] and [Box 2]. The studies are small with lower evidence levels and hence there are no standard guidelines available for management. From the evidence presented, it would appear that fractional laser and fractional MNRF should be the first line of management, but cost of these treatments and the large areas usually involved in stretch marks would be limiting factors. In such cases, peels or derma rollers with PRP may be a cheaper alternative.
Treatment of SD needs to be tailored to the emotional needs of the person, area of involvement and occupation. It should be made clear during counselling that as of now, none of the treatments can provide complete clearance and multiple sessions are always needed. The efforts should be to use topical therapies in combination with procedural modalities. The authors have made an effort to show these principles in the approach for management in below flow charts [Figure 1]a and [Figure 1]b.
|Figure 1: (a) Flowchart for management of striae distensae pre-treatment workup. (b) Flowchart for management of striae distensae – practical approach|
Click here to view
| Conclusion|| |
To offer an effective treatment of SD it is important to perform a complete evaluation of a patient including taking proper history, assessing type of SD and skin type of patient. Even in a patient who comes with realistic expectations, finding an effective treatment is often challenging for the treating physician.
There are various therapeutic strategies available, but so far no single modality is found solely effective. Multiple sessions using different therapeutic modalities targeting skin at different levels are often needed.
In future, more research with properly designed clinical trials with large sample size of patients, having longer follow-up periods and comparing different modalities are expected to address the issue of optimum management of SD.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]