Striae Distensae (Stretch Marks) Treatment & Management

In current practice, even with the significant dermatologic advances in topical medicaments and light-based devices, total resolution of these lesions remains an unattainable goal.

Avoidance of rapid weight loss or gain may help prevent the emergence of stretch marks, especially in high-risk groups such as teenagers and expecting mothers. Adolescents with striae can expect some improvement in their striae over time.

Striae distensae are most likely to respond to pharmacologic products and clinical interventions at their early stage (striae rubra). Once they become white (striae alba), only few treatment modalities exist and they are become quite difficult to treat.

Intensive moisturization of the lesions and the use of vitamin C, fruit acids, retinols, and other pharmaceuticals have been advocated for the early treatment of striae distensae rubra.

Topical application of tretinoin has been shown to significantly improve the clinical appearance of early striae distensae (striae rubra). ^{[6, 7, 8]} It should not, however, be used in pregnant or breastfeeding females, because of a theoretical concern about its teratogenic effects. The use of other retinoids such as adapalene and tazarotene may also hold promise in the treatment of striae distensae.

Al-Himadani et al correctly identified that no high-quality, randomized controlled trials evaluating treatments for striae distensae exist. ^[9] The following is a concise listing of available surgical modalities used in the treatment of striae distensae.

Treatment with the 585-nm flashlamp pulsed dye laser at low energy densities was shown to improve the appearance of striae. ^{[10, 11]} Multiple treatments at 4- to 6-week intervals are usually required. At a lower fluence (2-4 J/cm²), the 585-nm flashlamp pulse dye laser (FLPDL) has been purported to increase the amount of collagen in the extracellular matrix. The 585-nm FLPDL has a moderate beneficial effect in reducing the degree of erythema in striae rubra but has no apparent benefit in striae alba. Because of the potential for adverse effects, FLPDL treatments should be performed with extreme caution or even not at all in darker-skinned patients (phototypes V and VI). ^{[12, 13, 14]}

A study by Suh et al evaluated the effectiveness of using 585-nm pulsed dye laser with radiofrequency for striae distensae. Thirty-seven patients with abdominal striae distensae were treated with the Thermage and 585-nm pulsed dye laser in the first session at baseline. An additional 2 sessions of pulsed dye laser therapy were performed at weeks 4 and 8. Thermage was used at a fluence of 53-97 J/cm², and pulsed dye laser-therapy was used at a fluence of 3 J/cm² with a 10-mm spot. Skin biopsy specimens were taken from 9 patients. ^[15]

In the subjective assessment in the Suh et al study, 89.2% of the patients showed "good" and "very good" overall improvement, and 59.4% were graded as "good" and "very good" in elasticity. All of the 9 specimens showed an increase in the amount of collagen fibers, and increased elastic fibers were found in 6 specimens. The authors reported that Thermage and pulsed dye laser appear to be an effective treatment for striae distensae. ^[15]

In another study, involving the use of a 1064-nm long-pulsed Nd:YAG laser, Goldman et al reported subjective data (55% of patients reported excellent improvement) and objective photographic findings (40% of evaluating physicians reported excellent improvement). Minimal adverse effects were reported. ^[16]

Intense pulsed light, a noncoherent, nonlaser, filtered flashlamp that emits a broadband visible light, has been reported to yield clinical and microscopic improvement in striae distensae. It seems to be a promising treatment modality with minimal adverse effects and little-to-no down time. Its efficacy in the treatment of photodamaged facial skin has been widely reported; it promotes the production of neocollagen and elastic fibers. ^[17]

A study by Shokeir et al found that both pulse dye laser and intense pulse light can enhance the clinical picture of striae through collagen stimulation. ^[18]

A randomized pilot study by Hexsel et al found superficial dermabrasion to be as effective as topical tretinoin on early striae distensae. Additionally, superficial dermabrasion had a lower frequency of adverse effects and better adherence of the patients. ^[19]  Another study, by Ferreira et al, found that 10 treatments of galvano-puncture or dermabrasion produced similar satisfactory results on striae appearance. ^[20]  

Most of the enhancements in the treatment of striae pertain to striae rubra; only very limited modalities have shown promise in improving the appearance of striae alba. Lasers and light sources emitting UV-B irradiation (eg, the 308-nm excimer laser) have been shown to repigment striae distensae (striae alba). The improvement is due to an increase in melanin pigment, hypertrophy of melanocytes, and an increase in the number of melanocytes. ^[10]

In another study, a 1550-nm fractional photothermolysis laser was investigated for the treatment of striae distensae alba in Asian patients. Significant improvement in the appearance of the stretch marks was observed 2 months after treatment. Histologic examination revealed a substantial increase in epidermal thickness as well as collagen and elastic fiber deposition. Minimal pain and posttreatment hyperpigmentation were the main adverse events reported. Fractional photothermolysis laser treatments appear to improve the appearance of striae distensae alba, particularly through repetitive treatments. ^[21]

Pertaining to the use of carbon dioxide ablative fractionated lasers in the treatment of striae distensae, Alexiades-Armenaka et al found that the treatment gives rise to unpredictable results. "The data were inconclusive regarding the treatment of striae distensae following a series of treatments, with some patients demonstrating significant improvement while others showed no change from baseline." ^[22] On the other hand, other authors found benefit of using fractional photothermolysis via fractional carbon dioxide laser for treatment of striae alba. ^{[23, 24]}

Yang et al reported that nonablative fractional photothermolysis and ablative carbon dioxide fractional laser resurfacing are equally effective and safe treatment modalities for striae distensae in skin of Asian persons. However, neither treatment showed any greater clinical improvement than the other treatment. ^[25]  In a comparison of fractional carbon dioxide laser and carboxytherapy, both modalities produced significant reductions in striae dimensions and similar patient satisfaction. ^{[26, 27]}

Ryu et al reported on the efficacy of combination therapy of fractionated microneedle radiofrequency and fractional carbon dioxide laser as a safe treatment protocol with a positive therapeutic effect on striae distensae. ^[28]

In a study of 25 adults who received 1-3 microneedling treatments, there was at least 50% improvement in all striae. No permanent adverse effects were reported. ^[29]

Obagi et al had good success using low concentrations (15-20%) of trichloroacetic acid and performing repetitive papillary dermis-level chemexfoliation. The peels can be repeated at monthly intervals, with improvement in skin texture, firmness, and color. ^[30]

In a systematic review and network meta-analysis of common striae distensae treatments, Lu et al found bipolar radiofrequency combined with topical tretinoin to have the best clinical effectiveness and patient satisfaction ratings at 84.5% and 95.7%, respectively. ^[31]