Striae distensea
BACKGROUND Striae distensea (SD; stretch marks) are a well-recognized, common skin condition that rarely causes any significant medical problems but are often a significant source of distress to those affected. The origins of SD are poorly understood, and a number of treatment modalities are available for their treatment, yet none of them is consistently effective, and no single therapy is considered to be pivotal for this problem. With a high incidence and unsatisfactory treatments, stretch marks remain an important target of research for an optimum consensus of treatment.
OBJECTIVE To identify the current treatment modalities and their effectiveness in the treatment of stretch marks.
MATERIALS AND METHODS
Review of the recent literature regarding clinical treatment of stretch
marks with emphasis on the safety and efficacy of the newer optical
devices and laser applications.
RESULTS
No current therapeutic option offers complete treatment, although there
are a number of emerging new modalities that are encouraging.
CONCLUSION
The therapeutic strategies are numerous, and no single modality has
been far more consistent than the rest. The long-term future of
treatment strategies is encouraging with the advance in laser
technologies.
Successfully
treating striae distensae (SD; stretch marks) has always been
challenging. Nardelli gave the first morphologically correct description
of these lesions in 1936, calling them striae atrophicae.1 The exact origin of stretch marks remains unrevealed, with the factors responsible for its development poorly understood.2
Causes of SD are not clear, and a number of theories have been proposed (Table 1). Kogoj anticipated that a striatoxin damages the tissues in a toxic way, resulting in striations.3 Others had shown that mechanical stretching is the main cause, leading to the rupture of the connective tissue framework.4
Many authors have denounced this theory, not finding any relationship
between growth in abdominal girth in pregnant women and formation of SD.5
Normal growth has been suggested as another cause, with these marks
commonly developing during adolescence and associated with the rapid
increase in size of particular regions of the body.6
Similarly, SD are a feature of high serum levels of steroid hormones.
They are a common feature of Cushing's disease and local or systemic
steroid therapy may induce them. High steroid hormone levels have a
catabolic effect on the activity of fibroblasts and decrease the
deposition of collagen in the substance of the dermal matrix. Obesity
and rapid increase or decrease in weight have been shown to be
associated with the development of SD.7
Finally, the absence of striae in pregnancy in women with Ehlers-Danlos
syndrome and their presence as one of the minor diagnostic criteria for
Marfan syndrome emphasize the importance of genetic factors in
determining susceptibility of connective tissue.8 Similarly, there is low expression of collagen and fibronectin genes in affected tissue.9
| Different hypotheses on the development of stretch marks in the literature |
| Infection leading to the release of striatoxin that damages the tissues in a microbial toxic way3 |
| Mechanical effect of stretching, which is proposed to lead to rupture of the connective tissue framework (e.g., pregnancy, obesity, weight lifting)4 |
| Normal growth as seen in adolescence and the pubertal spurt that leads to increase in sizes of particular body regions6 |
| Increase in the levels of body steroid hormones; Cushing's syndrome, local or systemic steroid therapy that has a catabolic effect on fibroblasts7 |
| Genetic factors (absence of striae in pregnancy in people with Ehlers-Danlos syndrome and their presence as one of the minor diagnostic criteria for Marfan syndrome suggest an important genetic element)8,9 |
| Immunosuppression states associated with pregnancy-induced hypertension medications, human immunodeficiency virus or diseases such as tuberculosis and typhoid8,11 |
| Associated with chronic liver disease13 |
Other rarely reported causes of SD include cachetic states, such as tuberculosis and typhoid and after intense slimming diets.10 They may also be seen in anorexia nervosa.11
SD have been reported to occur rarely in patients positive for the
human immunodeficiency virus receiving the protease inhibitor indinavir.8 A case of idiopathic SD was also reported.12 Men and women with chronic liver disease may also have SD.13
Clinical Picture and Histopathology of SD
Recent
or immature SD are flattened areas of skin with a pink-red hue that may
be itchy and slightly raised. Stretch marks then tend to increase in
length and acquire a darker purple color. Over time, they become white,
flat, and depressed. Histologically,14
earlier-stage or immature SD tend to appear pink or red in color
(striae rubra) and over time and with atrophic changes attain a white
color (striae alba). High-resolution epiluminescence colorimetric
assessment of SD identified four distinct types: striae alba, striae
rubra, striae caerulea, and striae nigra. The direct and indirect
influences of melanocyte mechanobiology appear to have a prominent
effect on the various colors of SD.15
The
histology of stretch marks is that of a scar, and the development of SD
has been likened to that of wound healing or scar formation.16
In the early stages, inflammatory changes may be conspicuous, but later
the epidermis is thin and flattened. Recent SD show a deep and
superficial perivascular lymphocytic infiltrate around the venules.17
Collagen bands on the upper third of the reticular dermis are stretched
and aligned parallel to the surface of the skin. In the latter stages,
there is thinning of the epidermis due to flattening of the rete ridges
and loss of collagen and elastin.18
SD are two and a half times as frequent in women and affect up to 90%
of pregnant women. The commonest sites are the outer aspects of the
thighs and the lumbosacral region in boys and the thighs, upper arms,
buttocks, and breasts in girls.19
Recently it was demonstrated that SD are associated with loss of
fibrillin, a fact that explains the counter replacement of fibrillin
upon retinoic acid therapy.20
Treatments
Several
treatments have been proposed, yet no consistent modality is available.
Some authors, have suggested that time is the only treatment for SD and
that it returns to normal over years, which is not true.21
It has always been suggested that effective treatment of SD be
instituted during the active stage, well before the scarring process is
complete.22 The first reliable method of treatment involved using tretinoin cream.23
Subsequent modalities were reported afterward, with variable results,
which will be discussed in this section. A summary of major topical
treatments is given in Table 2.
| Product | Indication | Suggested Mode of Action |
|---|---|---|
| Tretinoin | Therapeutic | Exact mechanism unclear, but recent studies suggest fibroblastic stimulation. |
| Trofolastin | Therapeutic | Active ingredient (centella asiatica) stimulates fibroblasts and inhibits glucocorticoids. |
| Verum | Preventive | Active ingredient hyaluronic acid is speculated to increase tensile resistance to mechanical forces. |
| Alphastria | Preventive | Hyaluronic acid, the main ingredient, acts by increasing volume to oppose mechanical atrophy. |
| Massage with oils | Preventive | Dual action of massage and hydrant action of oils. |
| Glycolic acid and trichloroacetic acid peels | Therapeutic | Glycolic acid is reported to stimulate collagen production by fibroblasts and to increase their proliferation in vivo and in vitro. |
Diet and Exercise
There
is lack of data concerning the effect of diet and diet restrictions on
stretch marks. Eighty women aged 24 to 53 participated in a 3-month
weight-loss program; 29 were on a diet, 31 were on a diet plus aerobic
exercise program, and 20 obese women were on a diet plus a resistance
exercise program. The data suggested that the degree of SD does not
change with weight loss, regardless of the type of weight loss program.
SD were prevalent in 79% of the women. The central abdomen was the most
common area where SD were present. No significant correlation existed
between SD and the number of births, the age of the first birth, weight
immediately before pregnancy, weight immediately after pregnancy, or
weight at age 20. Forty-five percent of the participants responded that
they did not have negative feelings about having SD, and it appeared
that SD did not affect the women's psychological mood. It was inferred
that a weight loss program using diet alone or a combination of diet and
exercise did not change the degree of SD. Further studies are required
to establish a clear effect of diet and exercise on SD.24
Topical Therapies
Tretinoin
The
use of topical tretinoin has yielded variable results, and some of the
studies had proven the inefficacy of the vitamin A derivative in the
treatment of SD,25,26
but most of the patients included in these early studies presented with
old lesions that had evolved into whitish atrophic scars.25
More recently, tretinoin has been shown to improve the clinical
appearance of stretch marks during the active stage (striae rubra),
although with not much effect during the mature stage (striae alba).27 In the same study, 22 patients applied 0.1% tretinoin (n=10) or a placebo (n=12)
daily for 6 months to the affected areas. Patients were evaluated
monthly in a physical examination and using analysis of biopsy specimens
of stretch marks obtained before and at the end of therapy in
comparison with untreated normal skin. Targeted stretch marks in
patients treated with tretinoin had a decrease in mean length and width
of 14% and 8%, respectively, compared with an increase of 10% and 24%,
respectively, in patients who received the placebo. Rangel and
colleagues conducted an open multicenter study in Mexico on 20 women
with stretch marks after pregnancy. They all applied tretinoin (retinoic
acid) cream 0.1% daily for 3 months to pregnancy-related stretch marks
in the abdominal area. Efficacy was evaluated according to analysis of
one preselected target lesion, which was rated on a 6-point scale
(−1=worse to 4=cleared). All target lesions decreased in length by 20%,
and they demonstrated efficacy of tretinoin as a modality for treating
SD of pregnancy.28
Hydrant Creams
Anecdotal
treatments are numerous and unproven. Despite the general understanding
that proper hydration is necessary to maintain the integrity and
barrier function of skin, little in the literature is available on the
use of such creams in stretch mark prevention. Three studies involving
130 men in total were found.29
The active creams in the studies described are not widely available,
and it was not clear whether any particular ingredient was helpful. The
lack of clarity on the studies and the scientific data available makes
it difficult to conclude such creams are effective, and larger studies
are needed to determine the efficacy and safety of such products in
combating stretch marks.
Trofolastin One study involved 80 women and investigated the effect of massage with a cream containing Centella asiatica
extract, vitamin E, and collagen-elastin hydrolysates (Trofolastin,
Novartis Barcelona, Spain) and its preventive effect on the development
of stretch marks in pregnant women.30
Forty-one subjects used the cream, and 39 used a placebo. Results
showed that 56% of the placebo group and 34% of the treated group
developed SD in pregnancy. This study demonstrated that the active
component, Centella asiatica, induced significant prevention of
stretch mark development. The exact mechanism of action was identified
as the stimulation of fibroblastic activity,31 and an antagonistic effect against glucocorticoids was also reported.32
Verum
Another study of 50 women, although lacking a placebo control, examined
a cream containing vitamin E, panthenol, hyaluronic acid, elastin and
menthol (verum). It was associated with fewer stretch marks during
pregnancy than no treatment. One-third of women in the treated group and
two-thirds of those who did not receive any treatment developed SD
during pregnancy. The results suggest that the product could be helpful,
although the trial had no placebo and may show the benefit of massage
alone.33
Alphastria
Alphastria is a cream that is composed of hyaluronic acid, allantoin,
vitamin A, vitamin E, and dexpanthenol. The name is composed of the
Greek word “alpha” prefix meaning “without,” and the Latin word “stria,”
which means “lines.” Hyaluronic acid is an organic substance found in
human skin and is the main constituent of the cream. The hyaluronic
content stimulates fibroblast activity and collagen production to
restore any inhibition and collagen loss induced by hormonal
fluctuations or mechanical stretch.34
Only one study was conducted to demonstrate the efficacy and safety of
the cream. Thirty pregnant women were recruited to receive the cream,
and 30 others received a placebo as a control group. Three subjects in
the exposed group and 21 in the control group developed SD. The study
concluded that the product markedly lowered the incidence of stretch
mark development after pregnancy.35,36
Topical Oil Massage and Herbal Topical Remedies
Some
unconventional therapies and anecdotal reports recommend applying
unproven oils and natural remedies to stretch marks. The underlying
principle for this use would probably be keeping the skin well hydrated.
Sweet almond oil, wheat germ oil, olive oil, avocado oil, and castor
oil and applying seaweed wraps have these properties.37
Other remedies such as comfrey, hypericum, maritime pine, equisetum,
slippery elm, and wheat grass and eucalyptus tree oil are all used in
creams or oils, but no efficacy studies have been performed to support
these practices.38
Glycolic Acid and Trichloroacetic Acid
Glycolic
acid (GA) is an alpha hydroxyl acid. Although there are several reports
on the clinical effects of GA in rejuvenation, peeling, and photoaging,
no data on the effectiveness of GA to prevent stretch marks could be
found in the scientific literature. No epidemiological study on the use
of GA in pregnant women has been published. One study comparing topical
20% GA and 0.05% tretinoin with 20% GA and 10%l-ascorbic
acid found that both regimens improved the appearance of striae alba
and showed no difference in effect from combining 10% ascorbic acid or
0.05% tretinoin with 20% GA, although it was not determined which of the
ingredients provided the effect.39
The precise mechanism of action of GA is still unknown because the
biological effects of GA on cells has not been fully studied, although
GA is reported to stimulate collagen production by fibroblasts and to
increase their proliferation in vivo and in vitro.40,41
This mechanism can be useful for stretch mark treatments, but further
investigations and studies are required to prove such theory.
Trichloroacetic
acid (TCA; 10–35%) has been used for many years and is safe to use at
low concentrations. At higher concentrations (e.g., ≥50%), TCA has a
tendency to scar and is less manageable than other agents used for
superficial peels. TCA is found in several proprietary peels at varying
concentrations, and some kits have instructions and buffering agents so
that the peel can be diluted as deemed necessary. Anecdotal reports have
indicated the use of TCA in stretch marks, although there is a lack of
clarity and absence of data for assessment of this subject. Some authors
have had good success using low concentrations (15–20%) of TCA and
performing repetitive papillary dermis-level chemexfoliation repeated at
monthly intervals with reported improvement in texture and color of
marks.42,43
Other Topical Products
Hundreds
of products are available in the market, but the potential efficacy of
these products had never been subjected to any clinical investigation or
assessment. Moy has reported improvement with a topical agent alone
(Striae Stretch Mark Formula with Regenetrol Complex, Regenterol Labs,
Los Angeles, CA). Another formula available is
MACROdermabrasion/DermaPhoresis Topical Kit (IntegreMed, Scottsdale, AZ)
designed for use with positive-pressure salt microdermabrasion. Salt
A-Peel DermaPhoresis system (IntegreMed, LLC) was shown in one study of
12 weeks to attain a 39% improvement along with positive-pressure
microdermabrasion in 29 women with SD.14
Lasers and Light Devices
Of
the many modalities used to ameliorate and improve stretch marks,
lasers have recently become a popular therapeutic alternative. The
585-nm flashlamp-pumped pulsed-dye laser (PDL) is the most commonly
reported laser used in treatment of SD. The use of ablative technologies
such as the short-pulse carbon dioxide and erbium-substituted yttrium
aluminium garnet (YAG) enjoyed a brief popularity because of prolonged
healing and pigmentary alterations, especially in darker skin tones.44
Newer applications of other laser modalities such as neodymium-doped
YAG (Nd:YAG), diode, and Fraxel are finding a way into treatment of
stretch marks (Table 3).
| Type of Laser | Effectiveness in Striae Distensae |
|---|---|
| Pulsed dye laser | Demonstrated to be effective only for the immature element of striae (striae rubrae), targeting the vascular element. Not effective in darker skin and associated with pregnancy-induced hypertension. When combined with radio frequency, it showed a more promising response even on striae alba.46–48 |
| Copper bromide laser | A 577-nm laser that showed a mild to moderate effect in one study on skin types II and III; no histological analysis was carried out. Needs much evaluation.55 |
| 1,450 nm diode laser | Not useful in skin of color (IV–VI) and associated with many complications.57 |
| 1,064 neodymium-doped yttrium aluminium garnet laser | Targets immature striae and satisfactory results in the few studies so far.58–60 |
| Excimer laser | A 308-nm xenon-chloride laser with a good safety profile, although only repigments temporarily and does not have an effect of atrophy.53,54 |
| Intense pulsed light | A good alternative that was shown to be an effective tool in striae alba, although with a high incidence of pregnancy-induced hypertension.63 |
| Fractional photothermolysis | Fewer studies conducted, although all reported efficacy in mature and immature striae and demonstrated an increase in the number of collagen and elastin fibers and a good safety profile.70–73 |
Pulsed-Dye Laser
The
dilated blood vessels marked at the early stage of the stretch mark
formation render the striae rubrae a good candidate for PDL.45
According to McDaniel and colleagues and Alster, a clinical improvement
in immature SD is achieved after several courses of 585-nm flashlamp
PDL therapy using dynamic cooling.46,47 McDaniel demonstrated that the optimal treatment fluence was 3 J/cm2 using a 10-mm spot size.46
This laser has been purported to increase the amount of collagen in the
extracellular matrix. Jiminez and colleagues documented the
effectiveness of the 585-nm flashlamp PDL in stretch marks of skin types
I to IV and demonstrated that collagen changes precede any clinical
significant change,48
although it was also reported that, for darker skin tones (IV–VI),
laser treatment of SD should be avoided or used with great caution
because of the possibility of pigmentary alterations after treatment.49
Excimer Laser
Advances
in technology have recently brought the 308-nm xenon chloride (XeCl)
excimer laser to the laser arena. This newer technology allows treatment
of focal areas with a wavelength close to that of traditional
narrow-band ultraviolet B (UVB) light. Recent studies have demonstrated
efficacy of the 308-nm XeCl laser in the treatment of psoriasis50 and vitiligo.51
The 308-nm XeCl laser has the advantage over standard phototherapy of
having greater precision and the ability to deliver higher energy
fluences to the target tissue in less time. It is also possible that UVB
radiation delivered in the form of laser light has a different
light–tissue interaction, which may cause greater efficacy.52
After the use of the excimer in many hypopigmentary conditions, it was
used for striae alba. Two studies have shown temporary repigmentation
and improvement of leukoderma in SD with excimer laser. Post-laser
biopsies showed greater melanin content and hypertrophy of the
melanocytes, although it failed to show any improvement in skin atrophy.53,54
Copper-Bromide Laser
The
copper-bromide laser is a 577-nm laser that is only mentioned once in
the literature as being used for stretch marks. One study treated 15
patients with different stretch marks on different areas of the body,
exposing them to laser settings of 4 J/cm2 for SD on the breast in women or 8 J/cm2
for SD on other parts of the body. The study concluded that the
copper-bromide laser was effective in decreasing the size of the SD,
although further studies are needed to determine the ideal parameters
and the number of sessions needed for an optimum response.55
1,450-nm Diode Laser
The
diode laser is a midinfrared greater-than-700-nm non-ablative laser
technology with an integrated dynamic cooling device. In recent clinical
trials, this type of laser has demonstrated efficacy in the diminution
of rhytides, treatment of active acne, and improvement of atrophic
scars.56
Only one study examined the efficacy and safety of diode laser in the
treatment of 11 patients, Fitzpatrick skin types IV to VI. Patients were
assigned randomly to receive 4, 8, or 12 J/cm2 fluences, and
treatment sessions were offered every 6 weeks for a total of three
sessions. The incidence of postinflammatory hyperpigmentation was 64%,
and there was no improvement in the SD. It was concluded that, for skin
types IV to VI, treatment of SD is not useful, and the incidence of
postinflammatory hyperpigmentation is significant.57
1,064-nm Nd:YAG Laser
The
1,064-nm long-pulse Nd:YAG laser has also led to an increase in dermal
collagen when used in the nonablative treatment of facial wrinkles.58 In addition, this laser has a strong attraction to vascular targets59
that, associated with its action on dermal collagen, can lead to the
beneficial effects observed in the treatment of immature SD. The
histopathologic characteristics present in immature SD are similar to
those found in recent scars.60
This would explain why scars also show a significant improvement after
treatment with the 1,064-nm long-pulse Nd:YAG laser. A recent study used
the 1,064-nm Nd:YAG on immature SD in 20 patients, and observers and
patients identified results as satisfactory.61
Owing to its physical characteristics, represented mainly by the
1,064-nm wavelength, the laser used is safe. Complications rarely result
when the device and parameters are appropriately used in epilation or
vascular alterations, even in patients with dark skin. In addition, the
cooling of the SD before and immediately after the use of the laser
represents another factor in epidermal protection. More research will be
devised for a better cosmetic outcome and approach using the Nd:YAG
lasers.
Intense Pulsed Light
Intense
pulsed light (IPL) seems to be a good alternative treatment for SD. IPL
is characterized by a noncoherent filtered flashlamp with a broadband
spectrum (515–1,200 nm). Hernandez and colleagues used the IPL for 20
Hispanic patients of skin types III and IV and on long-standing mature
SD of the abdomen. All patients received five sessions, and the stretch
marks were biopsied before and after therapy. The study demonstrated an
overall significant difference in the post-dermal treatment thickness
and in the skin textures of the older stretch mark lesions.62
Studies have demonstrated that IPL replaced dermal elastosis with
neo-collagen, which explains its usefulness in improving stretch marks.63
UVB/UVA1 Combined Therapy
The
MultiClear device (Curelight Ltd., Gladstone, NJ) is a unique device
combining UVB and selective UVA1 wavelengths and emitting a
high-intensity noncoherent light with peaks at 313, 360, and 420 nm. It
is currently approved by the Food and Drug Administration (FDA) for use
in UVB phototherapy as well as psoralen plus UVA phototherapy to treat
psoriasis, vitiligo, atopic dermatitis, and hypopigmented scars. The
device achieves a repigmentary effect of unknown length because of the
lack of studies conducted. A study was conducted on nine patients with
mature striae alba who received 10 treatment sessions, and biopsies were
taken at the baseline and end of the study. At the end of the study,
all patients reported some form of hyperpigmentation that was transient
and did not affect any surrounding tissues. No changes were seen on
biopsy to indicate an effective remodeling collagen effect of the
device, although it needs further assessment.64
There have been no reports of greater incidence of skin cancer
development with this form of phototherapy, but further research is
prudent before establishing a safer profile of the device.64
Fractional Photothermolysis
Fractional
photothermolysis is a newer, nonablative resurfacing laser technique.
This 1,550-nm laser creates microzones or microthermal zones (MTZs) of
“injury” onto the skin. Within these areas, localized epidermal necrosis
occurs alongside collagen denaturation. Ultimately, the necrotic debris
is expelled, and neocollagenesis occurs. Additionally, because this
laser treatment is nonablative, the islands of normal skin serve to
speed the healing process. Fractional photothermolysis has been FDA
approved for dermatological procedures requiring the coagulation of soft
tissue; treatment of periorbital wrinkles; treatment of acne scars and
surgical scars; photocoagulation of pigmented lesions such as lentigos
(age spots), solar lentigos (sun spots), melasma, and dyschromia; and
skin-resurfacing procedures.65
There
are several studies confirming the efficacy of fractional
photothermolysis for treatment of facial scarring. Glaich and colleagues
reported on seven patients who were treated with fractional
photothermolysis for hypopigmented scars (secondary to inflammatory acne
or gas fire burn). Patients received two to four treatments at 4-week
intervals. No adverse events were noted. Independent physician clinical
assessment revealed improvements of 51% to 75% in hypopigmentation in
six of seven patients 4 weeks after final treatment.66
Alster and colleagues reported on 53 patients who were treated with
fractional laser photothermolysis for atrophic scars. No complications
or adverse events were noted. Ninety-one percent of patients had at
least 25% to 50% improvement after a single treatment; 87% of patients
receiving three treatments had at least 51% to 75% improvement in the
appearance of scars after 1 month, with stable improvement after 6
months.67
Hasegawa and colleagues treated 10 patients with acne scars using
fractional photothermolysis. There was no hyperpigmentation reported,
and results as seen by patients were successful.68
The histopathologic characteristics present in immature SD are similar to those found in recent scars.60
Some authors using hematoxylin and eosin or orcein stain reported
evidence of new collagen formation and demonstrated an overall increase
in the density of collagen after fractional photothermolysis.69
This mechanism is the anticipated mode of reversing the signs and
atrophy associated with stretch marks using fractional photothermolysis,
the technology receiving the most attention in this regard. There are a
few published studies on SD and fractional resurfacing. A 2007
Brazilian clinical study showed that Fraxel improved texture and
appearance of mature, white SD in skin types I to IV. Fifteen female
patients, skin types I to IV, with mature SD were treated with
fractional photothermolysis (1,550 nm Fraxel SL Laser). Treatments
included four to five sessions at weekly intervals, pulse energy of 8 to
10 mJ/MTZ, and a final density of 2,000 MTZs/cm2. The
treatment response was assessed by comparing pre- and 2-week
post-treatment clinical photography evaluated by two physicians and
patient questionnaires. The study demonstrated an early new indication
for stretch mark treatment with Fraxel.70
A Korean study used fractional photothermolysis on four patients of
skin type IV with striae gravidarum. All patients received just one
treatment and were assessed visually and histologically using skin
biopsy. The histology showed an increase in the number of elastic
fibers, and no side effects were demonstrated.71
A more recent study treated six patients with fractional
photothermolysis, and they all showed clinical improvement in melanin
and erythema indices and in elasticity. The authors demonstrated an
increase in collagen and elastin deposition in the dermis.72
The optimal settings and parameters to use have not been decided upon,
but investigators have shown promising results with three to five
treatments sessions with their therapeutic approaches.73
Microdermabrasion
Aluminum
oxide resurfacing has become a popular method of resurfacing.
Microdermabrasion is effective in many skin conditions such as acne
scars, mottled pigmentation, and fine wrinkles.74
It has been established too that microdermabrasion induces epidermal
signal transduction pathways that are associated with remodeling of the
dermal matrix. Microdermabrasion appears to set in motion a cascade of
molecular events capable of causing dermal remodeling and repair.75
There is a paucity of literature about the efficacy of
microdermabrasion in stretch mark therapy, but Mahuzier in his text book
on microdermabrasion stated that 10 to 20 sessions of microdermabrasion
at an interval of not less than 1 month, each session resulting in
bleeding points, provide satisfactory improvement in SD.76
A more recent Egyptian study on the clinical and molecular evaluation
of treating SD with microdermabrasion demonstrated a promising effect of
dermabrasion on stretch marks. The study used 20 patients with SD
receiving five microdermabrasion treatments at weekly intervals on half
of the body; SD on the other half of the body served as a control.
Biopsies from patients were analyzed using real-time reverse
transcriptase polymerase chain reaction for assay of type I procollagen
I-mRNA levels. The results showed an overall good to excellent response
in more than half of the subjects, with improvement more marked in
striae rubra, and upregulation of type I procollagen mRNA was found in
all treated SD samples.77 Further studies on a larger scale are needed to identify the efficacy of using such techniques for stretch marks.
Radiofrequency Devices
The
use of radiofrequency (RF) devices have been reported to be an
effective and safe noninvasive technique to tighten the face and neck
skin. Unlike lasers, which convert light to heat and target a specific
chromophore through the selective photothermolysis, RF devices transfer
higher-energy fluences to the skin through a coupling method. The
electrical energy transmitted is converted to heat upon reacting with
the skin's resistance.78 It is reported that collagen fibril contraction occurs immediately after RF treatments, which induces new collagen formation.79
A recent study evaluating the effectiveness of a RF device (Thermage,
Thermacool TC, Thermage Inc., Hayward, CA) in combination with PDL
subjected 37 Asian patients with darker skin tone with SD to a baseline
treatment with a RF device and PDL. This was followed by an additional
two sessions of PDL performed at weeks 4 and 8. Histological evaluation
was done on nine patients who were selected randomly; 89% of the
patients showed good to very good overall improvement, and 59% were
graded as good and very good in elasticity. All histological evaluations
demonstrated an increase in the amount of collagen fibers, and six of
the nine specimens showed an increase in the number of elastic fibers.
Hyperpigmentation developed in one study subject only and improved in 3
months.80
The effects of using RF devices in combination with lasers are yet to
be decided, but preliminary studies show a synergistic, effective, safe
modality that could be a good alternative for stretch mark therapy.
Summary
The
complete evaluation of a patient with SD should include consideration
of the SD stage (rubrae or alba) and of the skin type. Expectations must
be realistic, and the optimal treatment modality should be carefully
selected to avoid any exaggeration of the problem or complications. The
therapeutic strategies are numerous, and no single modality has been far
more consistent than the rest. Fractional photothermolysis, despite the
smaller number of preliminary studies, shows much promise in dermal
remodeling and subsequent improvement of white and pigmented SD.
Finally, more research and clinical trials should be encouraged to
address this cosmetic problem of concern to a large segment of women
worldwide.
References
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- 3Seitrag zur atiologie und pathogenese der stria cutis distensae. Arch Dermatol Syphiliol 1925;149:667.
- 4, , , et al. Mechanical factors in striae distensae. In: MorettigG, ReboraA, editors. Stria Distensae. Milan: Brocades; 1976. p. 87–96.
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