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Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Striae distensae (SD), or stretch marks, are common skin lesions that are medically benign but may lead to cosmetic and psychological morbidity. SD are dermal scars that commonly result from stretching of the skin in susceptible individuals. They commonly appear symmetrically in skin tension lines on the abdomen, breasts, hips, and buttocks. Striae are common in teenagers undergoing their growth spurts and in overweight individuals as well as in pregnancy, which are termed striae gravidarum. Striae rubra (SR) represent early striae which are linear, red-to-violaceous patches or plaques that may be pruritic. Gradually, they become white, atrophic, linear, depressed patches, which are referred to as striae alba (SA). Extensive striae that are deeper and wider may be seen with long-term systemic corticosteroid use or Cushing syndrome. Striae are likely the result of a combination of factors, including genetic predisposition, mechanical stress (e.g., growth spurt, bodybuilding, pregnancy), and hormones (e.g., systemic glucocorticosteroids, excessive potent topical steroids). SD are considered permanent, although some fading may occur, especially in adolescent striae. Histologically, early striae show dermal edema with perivascular lymphocytes and, over time, epidermal and dermal atrophy develops.
Management Strategy
Treatments ranging from topical therapies to lasers and light-based devices have been investigated to improve SD. No treatment can completely eradicate SD, but an improvement in cosmetic appearance can be gained. Treatments aimed at increasing collagen production, decreasing redness in SR, and/or improving pigmentation in SA are the most utilized.
The goal of treatment is an acceptable aesthetic improvement, making realistic patient expectations essential. Currently, there is no ‘gold standard’ treatment, but a combination approach with earlier intervention may yield the best results.
Several studies have shown that topical tretinoin improves the appearance of striae. There are some conflicting reports, however. Centella asiatica appears better used as a prophylactic in a trial with pregnant women but has been combined with other ingredients like onion extract , hyaluronic acid , and silicone , showing variable results.
Other therapies, including chemical peels , microdermabrasion , platelet-rich plasma (PRP) , and microneedling (also known as percutaneous collagen induction therapy ), have shown promising results. The authors are skeptical of lighter peels because they do not have sufficient dermal penetration.
Lasers can be more aggressive but do not necessarily improve efficacy. Caution about downtime and side effects like postinflammatory hyperpigmentation (PIH) must be taken when using certain devices. Both ablative and non-ablative fractional lasers have produced favorable results. Radiofrequency devices are gaining popularity and results are encouraging.
Vascular devices, including the 585-nm pulsed dye laser (PDL), neodymium-doped yttrium aluminum garnet (Nd:YAG), and intense pulsed light (IPL), have shown efficacy primarily in improving the redness of SR. UV light and xenon-chloride excimer laser have been used to stimulate pigmentation in SA with results that appear to be transient.
Specific Investigations
The diagnosis and cause of striae are usually straightforward to elucidate. When the lesions are particularly severe and the cause is unknown, laboratory testing to exclude Cushing syndrome is advised. Occasionally, striae may be confused with linear focal elastosis, which are striae-like, asymptomatic, slightly palpable, yellow bands commonly found on the lower back of older adults. Hypermobile Ehlers-Danlos syndrome (hEDS) and Marfan syndrome are two important conditions to be aware of. Marfan syndrome presents with unusually distributed striae in a tall, young patient, and early diagnosis can help prevent fatal aortic aneurysm rupture. In hEDS, patients present with easy bruising, soft skin, and joint laxity, but unexplained striae may aid in the diagnosis.
Observation is the route that most people choose, especially in mild cases. Given the lack of reliable therapeutic modalities, their associated costs, and potential side effects, observation may be warranted in selected cases. Specifically, adolescent striae that appear after growth spurts may become less conspicuous over time. However, for most patients seeking improvement, observation is not recommended.
Adolescent striae
Topical tretinoin (retinoic acid) improves early stretch marks
Kang S, Kim KJ, Griffiths CE, et al. Arch Dermatol 1996; 132(5): 519.
This double-blind, randomized, vehicle-controlled trial studied 22 patients who used either 0.1% tretinoin nightly ( n = 10) or vehicle ( n = 12) for 6 months. After 2 and 6 months of treatment, striae were significantly improved in the treatment group. At 6 months, mean length and width decreased in the treatment group, whereas they increased in the control group.
Treatment of striae distensae with nonablative fractional laser versus ablative CO 2 fractional laser: a randomized controlled trial
Yang YJ, Lee GY. Ann Dermatol 2011; 23: 481–9.
Twenty-four patients with abdominal SA were enrolled in a randomized, double-blind, split study. They were treated with 1550-nm fractional Er:glass laser (pulse energy [PE] of 50 mJ, spot density of 100 spots/cm 2 , scan area of 5×10 mm) and ablative fractional CO 2 laser resurfacing (PE 40–50 mJ, spot density 75–100 spots/cm 2 , scan area of 8×8 mm). Each half of the lesion was treated three times at 4-week intervals. Pain, PIH, and crusting were seen in both treatments but worse on the CO 2 side. Although no significant differences were seen between the two groups, clinical improvement was seen in 91% of patients. Patients reported 82% improvement with the non-ablative vs. 91% improvement with the ablative.
Treatment of striae distensae with fractional photothermolysis
Bak H, Kim BJ, Lee WJ, et al. Dermatol Surg 2009; 35: 1215–20.
In total, 22 Asian women were treated with two laser treatments (Fraxel SR1500) separated by 4 weeks at PE 30 mJ, density level of 6, and eight passes. Comparing pretreatment and 1-month posttreatment photos, six of 22 (27%) demonstrated marked improvement while the remaining 16 showed mild improvement. Outcomes were better in patients with white rather than red striae.
Treatment of striae distensae using an ablative 10,600-nm carbon dioxide fractional laser: a retrospective review of 27 participants
Lee SE, Kim JH, Lee SJ, et al. Dermatol Surg 2010; 36: 1683–90.
In this review, 27 women with striae were treated with one session of fractional CO 2 Ultrapulse Encore System’s DeepFx mode at PE of 10 mJ and density of 2 (10% coverage) with spot diameter of 1–10 mm. Three months after treatment, 7.4% had grade 4 clinical improvement, 51.9% grade 3, 33.3% grade 2, and 7.4% grade 1. None of the participants showed PIH or worsening.
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