Expert advice on the most effective preventative measures as well as treatments available to tackle this cosmetically stressful condition.
Striae distensae, or stretch marks, are scar tissue in the dermal layer of the skin that result from rapid growth or weight gain. As such, these lesions, which can be found crisscrossing the breasts, abdomen, hips, thighs, buttocks and arms, occur in females and males, particularly as a result of adolescent growth spurts, pregnancy, obesity, rapid muscle growth (e.g., from weight lifting) and prolonged use of topical steroids. In these instances or periods of growth, collagen and elastin are not produced quickly enough to accommodate the expansion of other cutaneous layers, rendering the normally elastic dermis less flexible and manifesting in visible epidermal marks. Initially, these dermal alterations present as pink, red or purple lesions, known as striae rubra. The lesions, if untreated, become white (striae alba) and the texture of the lesion may change from swollen to flattened or moderately depressed. A high proportion of teenage girls as well as pregnant women are beset with striae distensae. Fortunately, the modern dermatologic armamentarium features various options to tackle this cosmetically stressful condition, including novel laser options for treating striae alba. In this discussion, I will briefly address the few available preventive measures before considering the topical as well as laser treatments for striae distensae Prevention There is no surefire method of preventing the development of stretch marks per se, but the avoidance of a rapid gain or loss of weight improves one’s chances of not developing these lesions. Several topical agents have also demonstrated efficacy in high-risk patients. For individuals who are pregnant or experiencing adolescent hormonal changes, moisturizing regularly, three to four times daily, is recommended. Skin becomes more pliant and elastic when well hydrated. Moisturizers that contain cocoa butter, shea butter or Centella asiatica (also known as gotu kola) as a prime ingredient are the best. To increase their efficacy, such formulations should be massaged deep into the affected area(s). I recommend Belli Elasticity Belly Oil, which contains healthy amounts of both cocoa butter and Centella asiatica, to my patients. At-Home Treatment Identifying striae distensae early is crucial. Patients should be advised to seek treatment when stretch marks are still red or purple. The condition is most likely to respond to at-home products and in-office peels at this stage. Once the stretch marks are white, the treatment becomes more difficult and less successful. Striae rubra may respond to the glycolic acid in various over-the-counter (OTC) brands, most likely due to the alpha hydroxy acid’s capacity to stimulate collagen synthesis. I recommend the brands with the highest concentration of glycolic acid, such as MD Forté Glycare I and NeoStrata Ultra Smoothing Lotion. Vitamin C, if formulated properly, also has the capacity to promote collagen synthesis. It can be used individually or in combination with glycolic acid. I recommend SkinCeuticals C E Ferulic and La Roche-Posay Active C. Daily supplementation with oral vitamin C 500 mg twice daily may also confer some benefit. Relastin, marketed as an eye cream and a face cream, is touted by its manufacturer for increasing elastic tissue, which may ameliorate stretch marks. Its efficacy remains unconfirmed at this point but studies are ongoing. Retinoids:Studies In an early study of retinoids for the treatment of striae distensae, 16 of 20 patients with stretch marks due to various causes completed the study; 15 of them exhibited significant clinical improvement.1 Retinoids promote collagen and elastin production. When retinoids are massaged nightly into striae rubra, the appearance and texture of the lesions can improve significantly. In fact, the use of 0.1% tretinoin for the treatment of striae rubra has been established as effective for more than a decade.2 Retinoids are not as effective for the treatment of striae alba, however, and are contraindicated in pregnant or breastfeeding women. In a decade-old study evaluating commercial topical products for the treatment of striae alba, investigators tested two topical regimens on 10 patients with abdominal striae alba with Fitzpatrick skin types ranging from I to V. On a daily basis for 12 weeks, patients applied 20% glycolic acid (MD Forté) on the whole treatment area. Also, on half of the treatment area, patients were directed to apply 10% L-ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine cream, and 0.05% tretinoin emollient cream (Renova) to the other half. Improvement in the appearance of stretch marks, assessed at 4 and 12 weeks, was documented in both regimens, which were seen as safe and effective. In addition, in a comparison of treated stretch marks with untreated lesions, both regimens were found to be effective in decreasing papillary dermal thickness and increasing the epidermal thickness of treated striae alba; the combined thickness of these layers approached that of normal skin. The researchers also found that the use of the glycolic acid and tretinoin combination augmented the elastin content in the reticular and papillary dermis.3 In another study evaluating the effects of a retinoid, 20 women applied tretinoin cream 0.1% to abdominal striae induced by pregnancy. In this open-label, multicenter, prospective study conducted over 3 months, the efficacy of the daily applications was assessed by analyzing a pre-selected lesion. Researchers observed marked improvement in all striae after 3 months compared to baseline, with a 20% reduction in the target lesion on average. Despite the emergence in 11 patients of erythema and scaling (minor adverse reactions that diminished in intensity after 1 month of treatment coupled with petroleum jelly ointment application), the investigators found that topically applied tretinoin significantly ameliorated pregnancy-induced striae distensae.4 Recommended Retinoids I recommend OTC retinol products such as Philosophy Help Me and Neutrogena Healthy Skin to my patients. Of course, prescription retinoids such as Retin-A Micro, Tazorac and Differin are stronger and therefore may be more effective than retinols. I also suggest retinoic acid peels, such as the Ultra Peel Exfoliating Treatment or the Esthetique Peel from PCA Skin. In-Office Treatment Topicals Glycolic acid can be administered in-office at higher doses than that contained in available OTC products. After three or four visits, patients usually notice a slight change in the length, width and intensity of striae rubra. In-office glycolic peels are safe for all skin types, although lower concentrations should be used for those with darker skin tones. As suggested above, the combination of glycolic acid and a retinoid can be effective. In fact, various prescription-strength retinoids are often applied as a preparation for a glycolic acid peel. Lasers Vascular lasers can also offer outstanding results. Because vascular lasers are designed to work with dilated blood vessels, which are characteristic of striae rubra, they present a potent treatment option. These instruments are associated with epidermal turnover as well as increased collagen production and elastic remodeling. Most often, three to six sessions are required. I prefer the Dornier 940-nm laser for stretch marks, but some physicians use the 585-nm or 595-nm laser, which are also effective. In a recent study, investigators treated 20 patients with striae rubra using the 1064-nm long-pulsed Nd:YAG laser, which has been successfully used to foster dermal collagen synthesis. Subjective evaluations were made by patients (with 55% rating the results as excellent) and the investigators used before-and-after photos to assess treatment efficacy. Forty percent of the doctors considered the results to be excellent. Overall, the investigators found the 1064-nm long-pulsed Nd:YAG laser to be an effective option for treating striae rubra, with minimal side effects.5 In another recent study, investigators evaluated the efficacy of the Thermage laser (Therma Cool TC; Thermage Inc., Hayward, CA) in combination with a 585-nm pulsed dye laser for the treatment of striae distensae in people with darker skin types. At baseline, 37 Asian patients with abdominal stretch marks were treated with both modalities. Treatment with the pulsed dye laser only was repeated at the 1-month and 2-month points after the initial combined therapy. Overall improvement was termed “good and very good” by 89.2% of the participants in the subjective evaluation, with 59.4% achieving “good and very good” elasticity. In addition, nine patients were skin biopsied, with the level of collagen fibers shown to be increased in each sample; six of the specimens exhibited an increase in elastic fibers. The investigators concluded that striae distensae can be effectively treated in darker skin types with the combination of the Thermage and pulsed dye lasers.6 It is worth noting that in a previous study on patients with dark skin types (Fitzpatrick IV to VI), researchers studied the effects on striae distensae with the non-ablative 1450-nm diode laser. Eleven Asian patients were treated with the laser with cryogen cooling spray on one half of the body (abdomen, arms, back, buttocks, and thighs) and the other half served as the control, for a total of three treatments performed at 6-week intervals. Assessments of before-and-after clinical photographs were made by non-treating physicians, who found that no patients experienced visible improvement over 2 months. The investigators concluded that for patients with skin types IV to VI, the non-ablative 1450-nm diode laser is not a viable option for treating stretch marks.7 Intense Pulsed Light Based on the reported efficacy of intense pulsed light (IPL), a noncoherent, nonlaser filtered flashlamp, to foster the synthesis of collagen and ordering of elastic fibers, investigators conducted a prospective study of 15 women with abdominal striae distensae to examine the effects of IPL on stretch marks. Before-and-after photos and skin biopsies were taken of all subjects, each of whom underwent five IPL sessions once every two weeks. All 15 patients exhibited significant clinical and microscopic improvements, including differences in dermal thickness. The investigators concluded that IPL is an effective and safe option for treating striae distensae and requires no downtime.8 A more recent examination of an IPL infrared device, the NovaPlus, which attains high fluences with high-frequency stacked pulses, on striae distensae was conducted on 10 patients. Directed to maintain their weight throughout the duration of the study to reduce the chances of influencing the lesions, participants received three passes during each of four sessions scheduled 15 days apart. The investigators noted mixed results in what they admitted w as a small study. Review of before-and-after photographs and three-dimensional skin surface analysis yielded an equal outcome and few subjects observed improvement. However, histologic assessment did reveal improvement in epidermal and dermal condition. The researchers concluded that, given the absence of side effects in particular, additional treatment sessions may afford better chances for desired cosmetic results.9 Fractional Photothermolysis Despite the enhancements in overall treatment of striae distensae, few modalities have provided promise in significantly improving the appearance of striae alba — perhaps until now. In a recent study of the safety and efficacy of fractional photothermolysis (FP) for the treatment of stretch marks in Asian skin, researchers irradiated the striae distensae on the right buttocks of six female volunteers (ranging from 20 to 35 years old) using a 1550-nm FP laser. Patients were followed every month for a total of 2 months. Fleeting mild pain and hyperpigmentation were the adverse events reported. Overall, significant amelioration 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. Also, investigators noted that skin elasticity had become somewhat normalized. They concluded that FP promotes the production of collagen and elastin and, thus, can improve the appearance of striae distensae, particularly through the use of repeated treatments.10 Such a study suggests that in addition to the FDA-approved uses for FP lasers (acne, rejuvenation and melasma), this new instrument is suitable for treating striae alba. Many physicians have begun using the Fraxel laser for such purposes and have achieved good results. Nevertheless, completely eradicating these lesions remains unlikely with extant treatment modalities. Conclusion While preventive measures can be enacted to reduce the likelihood of developing stretch marks, these lesions can be challenging to prevent. Treatment options are continually expanding for this unsightly and stressful but innocuous condition that is derived from rapid skin growth or expansion. Glycolic acid and retinoids have demonstrated efficacy in in-office procedures as well as in OTC products. Vitamin C may also impart some benefit. Significantly, lasers have emerged as viable treatment options. The vascular laser is recommended for striae rubra and the Fraxel laser for striae alba. Patients are advised to begin at-home treatment for stretch marks upon first noticing them and scheduling a dermatologic visit. Dr. Baumann is Director – University of Miami, Cosmetic Medicine and Research Institute, and Professor of Dermatology.