Stretch marks treatment, what works?
What is stretch marks
striae distensae ( Stretch Marks), also known as stretch marks, are common, permanent dermal lesions that can be symptomatic and are considered aesthetically undesirable; thus, they pose a significant psychosocial and therapeutic challenge. SD arise in areas of dermal stretching and most commonly occur on the abdomen, breasts, buttocks, and thighs.1-3Most literature has described stretch marks during pregnancy (striae gravidarum) and puberty, with reported prevalences varying from 11% to 88%. Hormonal influences,8-12 reduced genetic expression of fibronectin, collagen, and elastin,13,14 and mechanical stretching of the skin2,15-17 have all been postulated to contribute to SD formation. In the acute phase, SD appears as red/violaceous lesions (striae rubrae; SR) that can be raised and symptomatic. The chronic form (striae albae; SA) exists as hypopigmented dermal depressions. Because of their high prevalence and impact on patients’ quality of life,20 there is great demand for an effective treatment. A vast array of treatment modalities have been investigated, ranging from topicals and acid peel treatments21 to more invasive methods such as laser therapy. Although complete eradication of SD is not attainable, improving the appearance whilst reducing physical symptoms certainly is. It is therefore essential that clinicians managing SD have a detailed understanding of available treatment strategies to optimize patient outcomes and
expectations. We herein present a systematic review of SD, focusing on the different treatments and their proposed modes of action with outcomes, in relation to
the histopathogenesis of the condition.
Tretinoin (retinoic acid)
is believed to increase tissue collagen I levels through stimulation of fibroblasts and has inhibited activation of matrix-degrading enzymes after ultraviolet (UV)-induced skin damage, which implies that it may also protect the skin from other mechanisms of injury. Numerous studies have investigated its efficacy (LOE 1, 2, 4), with the majority suggesting that it can improve the appearance of early SD but not at lower doses.However, study populations were small, and common side effects included transient erythema and scaling of the skin.
is a plant used in Asian herbal medicine. It contains asiaticoside, which stimulates fibroblasts, with antagonistic effects on glucocorticoids also described. Its use in the prevention of stretch marks gravidarumhas been investigated, with reported reductions in the development and severity of stretch marks (LOE 1).No side effects were observed. The use of Centella asiatica combined with boswellic acid, previously found to have anti-inflammatory effects, has also been tested. Reductions in stretch marks severity were noted; however, side effects included pruritus (LOE 4).
Hyaluronic acid is also thought to increase collagen production through stimulation of fibroblasts. Two randomized, controlled trials (RCTs) (LOE 1) have reported improvements in the appearance of stretch marks after its use, with a reported side effect being pain after treatment. No follow-up was conducted, and both incorporated subjective assessments of their outcome measures.
Chemical peel treatments
Chemical peel treatments involve the application of trichloroacetic acid or glycolic acid (GCA). They are thought to induce an initial inflammatory response, with subsequent increased collagen production. A nonrandomized, controlled trial investigating GCA reported decreases in stretch marks furrow width but concluded that it may yield better results when used in combination with other products. GCA combined with tretinoin and L-ascorbic acid and trichloroacetic acid combined with the use of sand abrasion or postpeel creamare such examples, all of which produced improvements in the appearance of stretch marks. No RCTs have been performed (GCA: LOE 2; trichloroacetic acid: LOE 4), and postinflammatory hyperpigmentation (PIH) remains a concern.
microdermabrasion mechanically ablates damaged skin. A study investigating its use in SD reported clinical improvements and increased type 1 procollagen formation (LOE 2).Reported side effects included PIH.
Radiofrequency (RF) devices (Ultrashape) deliver RF current to the skin, which is converted to heat in the dermis as the result of its electrical resistance. After initial collagen denaturation with its use, there is subsequent increased collagen production. The majority of trials investigating RF (ultrashape) for the treatment of SD have reported clinical improvements (LOE 1, 2, 4). However, side effects include erythema and edema, and the majority of trials had small cohorts.
Fractional lasers (Fraxel) deliver microscopic beams of coherent and monochromatic light energy to the skin, creating areas of thermal damage termed microthermal zones, leading to increased dermal collagen production. Both ablative and nonablative lasers (Fraxel) are available, with ablative lasers targeting water and resulting in cell vaporization. Improvements in SD after treatment with a 1540-nm fractional nonablative erbium glass laser (Fraxel) have been reported (LOE 1, 2, 4). However, Malekzad et al observed only a fair or poor improvement in 70% of patients with its use (LOE 4), and, although improvements in SR have been described (LOE 4), the literature suggests that nonablative lasers are most effective on SA (LOE 4). Concerns surrounding PIH also remain.
Fractional ablative carbon dioxide lasers have primarily been used in SA, with reported clinical improvements (LOE 2, 4). Side effects include PIH. Gungor et al compared the efficacy of an ablative erbium-yttrium aluminum garnet laser with a nonablative neodymium-doped yttrium aluminum garnet laser and found poor clinical results with both (LOE 2). The literature suggests that, when compared with nonablative lasers, ablative lasers are less well-tolerated and produce inconsistent results.
The 1450-nm diode laser is a nonfractional laser that has been shown to increase dermal collagen. However, an RCT investigating its use in Fitzpatrick skin types IV-VI reported no improvements in SD but demonstrated high rates of PIH (LOE 1).
Intense pulsed light
Intense pulsed light consists of a broad-spectrum (515-1200 nm) visible beam of high-intensity light. Studies investigating its use in SD have demonstrated increased dermal collagen levels after treatment (LOE 4). However, a study comparing intense pulsed light against a fractional carbon dioxide laser for the treatment of SD concluded that the laser was more effective (LOE 2). No RCTs have yet been performed, and PIH remains a cause for concern.
Percutaneous collagen induction therapy(microneedling), involves the creation of micro clefts extending to the papillary dermis, resulting in increased production of collagen and elastin Aust et al reported improvements in skin texture and tightening after treatment (LOE 4). More recently, percutaneous collagen induction therapy compared favorably against microdermabrasion combined with sonophoresis and against a carbon dioxide laser (LOE 2). However, there are no RCTs, and side effects include erythema.
Platelet-rich plasma (Vampire facial)
Platelet-rich plasma (PRP) is a concentrated solution of autologous platelets containing growth factors and cytokines injected intradermally. Ibrahim et al investigated its use in SD with microdermabrasion, and, despite increased collagen levels after PRP treatment alone, 13% had worsening of their stretch marks (LOE 2). They concluded that it is best to use PRP in combination with microdermabrasion. Other studies have combined PRP with RF (LOE 4) and microneedling (LOE 2), all reporting varying degrees of clinical improvement. However, small sample sizes and no RCTs make drawing definitive conclusions difficult. Side effects include bruising.
Infrared light applied to skin causes heating of the dermis and collagen denaturation, with subsequent neocollagenesis. Trelles et al investigated its use in the treatment of SA. Despite positive histologic findings, including more pronounced rete processes, detection of improvements clinically remained low (LOE 4). Side effects were limited to erythema of the skin.
The 585-nm pulsed dye laser (PDL) is a commonly used vascular laser. Because of its high affinity for hemoglobin, which is present in the microvasculature of SR, it can reduce the erythema of these lesions (LOE 2). Although improvements in both collagen and elastin have been described after PDL treatment, these are probably subclinical, and PDL is likely to have minimal benefit in the treatment of SA (LOE 2, 4), Care should be taken when using PDL with darker skin types (Fitzpatrick IV to VI) because melanin competes with hemoglobin for the light energy, which can result in PIH. Longo et al. tested the 577-nm copper bromide laser, which has higher rates of absorption by hemoglobin than its PDL counterpart; 33% had complete resolution of their SD, with the remainder showing a reduction in stretch marks size (LOE 4). Crusting of the skin was a reported side effect. The neodymium-doped yttrium aluminum garnet vascular laser has also produced clinical improvements in SR (LOE 2,4); however, side effects include PIH
We at Albany cosmetic and laser center offer most of the of discussed treatment fractional laser (Fraxel), Radio-frequency fractional microneedling, microdermabrasion silk peel, palette-rich plasma injection (PRP, vampire facelift) and much more… We offer bundles of all treamtent at discounted rate . consultation is always free
Important note: this post was created by copying and citing an article by Bayat et al., entitled “Therapeutic targets in the management
of striae distensae: A systematic review” publish on Journal of the American Academy of Dermatology
Dr. Kamal Alhallak
Ph.D., MSc, CDE, CRE, APA, MBA candidate