Striae: Etiology and Challenging Therapies

Striae distensae, or stretch marks, represent a common form of dermal scarring that appear on the skin as early erythematous, violaceous striations (striae rubra), or later hypopigmented atrophic linear lines (striae alba).  Although typically asymptomatic, striae distensae may be disfiguring and psychologically distressing to patients, especially in visible areas of the body.  Common locations are the abdomen, breast, medical upper arms, hips, lower back, buttocks, and thighs.

Epidemiologic data in the general population are limited but have been reported from as low as 11% in normal men to up to 88% in pregnant females.  Predisposing factors include pregnancy, adolescent growth spurts, rapid weight gain or loss, obesity, drug exposure (corticosteroid medication), underlying disease (Cushing’s Syndrome, Marfan Syndrome), and surgery (augmentation mammoplasty).  The etiologies are unknown but may be caused by stretching of skin─ the severity may be affected by genetic tendencies, degree of stress on the skin, and cortisone levels (weaken dermal elastic fibers).

Striae distensae are basically scars where the epidermis is flat and the dermis is thinned. Changes in connective tissue within striae consist of linear tears and reduction of altered dermal collagen and thinning or absence of altered elastic fibers.  There is usually a perivascular inflammatory reaction and swelling around the scar.

Multiple treatment modalities have been published with mixed results.  The best results have been observed in the treatment of striae rubra.  Both the increased vascularity and atrophic aspect of the scar need to be addressed.  Treatment for stretch marks can be costly and is not always effective.  Current treatments are particularly limited in their ability to deliver long-lasting improvements for all skin types. 

Preferred Initial Therapies

     ▪ Topical treatments (steroids, tretinoin cream)

     ▪ Chemical Peels

     ▪ Superficial dermabrasion (combination treatments with tretinoin cream or PRP) 

     ▪ Microneedling with or without radiorequency (mild-moderate improvement)

     ▪ Phototherapy (Intense Pulse Light)

     ▪ PhotoDynamic therapy (ALA/MAL)

     ▪ Non-ablative fractional lasers (mixed improvement)

     ▪ Ablative fractional lasers (mixed improvement)

     ▪ Combination therapies (for example, microneedling-RF and PRP)

Summary

Striae distensae is a common disorder, can be a source of substantial distress, and remains a challenge to treat.  Combination therapies have yielded promising results, but larger randomized controlled studies are required to validate prevention and treatment options. Although Dr. Sasaki and his staff will advise you about safe and potentially effective treatments, the complete eradication of striae continues to be elusive and challenging.

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