The Treatment of Striae – Where is The Evidence?

 With no gold normal method to deal with stretch marks, Firas Al-Niaimi evaluations the literature to establish essentially the most appropriate therapy choices

Striae distensae (SD), often known as stretch marks, are widespread cutaneous lesions characterised by linear bands of atrophic pores and skin1. They signify dermal scars with epidermal atrophy and pose a standard supply of beauty concern. Striae distensae end result from modifications within the collagen, brought on by fast stretching of the pores and skin, and are normally a number of and symmetrically distributed2. Probably the most generally affected websites embody the stomach, outer thighs, and breasts2,3. Regardless that the precise pathogenesis is poorly understood, striae are generally related to mechanical stress (fast weight modifications and development spurt) and hormonal modifications (being pregnant, oral contraceptive use, elevated adrenocortical perform, and corticosteroid remedy)3. The evolution of SD proceeds by way of a number of levels. Within the acute stage, they could be skinny, pink, and even pruritic. Over time, they normally enlarge in size and width, might turn out to be raised, and purchase a reddish-purple look (striae rubra — SR). Lastly, they turn out to be flat or depressed and hypopigmented (striae alba — SA)3,4.

Histologically, SD demonstrates the same look to atrophic scars. They show epidermal atrophy, flattening of the rete ridges, lack of thickness within the dermis, in addition to retraction and lack of collagen and elastin3,4.

A number of remedies have been utilized with variable therapeutic outcomes, price, and side-effects. At current, there isn’t a universally accepted therapy for all sorts of SD and in all pores and skin sorts, making enchancment moderately than full decision a extra sensible medical expectation4. Out there remedies embody topical brokers, chemical peels, microdermabrasion, and a large number of each ablative and non-ablative energy-based gadgets.

Literature outcomes

A complete of 30 research have been discovered that used energy-based gadgets as a therapy of SD between 1999 and 2017. Of those research,

laser classes included: non-ablative fractional laser, radiofrequency, long-pulsed Nd:YAG, fractional CO2 laser, fractional bipolar radiofrequency, fractional ablative

microplasma, pulsed dye laser (PDL), and intense pulsed mild( IPL). A complete of

eight research have been discovered that used topical remedy as a therapy of SD between 1994 and 2017. Remedy remedy included: Punica granatum seed oil, Croton lechleri resin extract, galvanopuncture, platelet-rich plasma (PRP), topical tretinoin, glycolic acid, and ascorbic acid. Needling and micro-dermabrasion have been additionally reported in a small variety of research.

Of the research which used energy-based gadgets as a therapy, 16 of those have been comparative research, 4 have been mixture research and the remaining 10 have been non-comparative/non-combination research. Of the research which used topical remedy as a therapy, three of those have been comparative research, three have been mixture research, and two have been non-comparative/ non-combination research.

Non-comparative/non-combination research

Pongsirhadulchai et al. reviewed the efficacy and security of fractional radiofrequency (FRf) for SA in 33 topics with SA affecting the thighs, buttocks, and stomach. Three periods of FRf have been undertaken at 4-weekly intervals, and post-treatment outcomes have been assessed utilizing digital Pictzar software program to find out if the size and width of SA had lowered. They discovered a major discount within the size and width of the SA from baseline (P<0.001). Histopathology of the SD was additionally reviewed post-treatment, which demonstrated collagen and elastin bundles have been discovered to be considerably elevated5.

Clementoni and Lavgno handled 12 Caucasian sufferers with three periods of fractional non-ablative 1565 nm fractional laser and reviewed the outcomes at 3-months post-therapy. Good medical enchancment was present in all sufferers handled, with the quantity of the depressions and enchancment of lesion color being the subcategories that have been optimized essentially the most. Transient side-effects included transient erythema and oedema; nevertheless, neither have been lengthy lasting6.

One other research involving 22 sufferers with SD used two periods of 1550 nm fractional non-ablative laser at 4-weekly intervals and evaluated the outcomes utilizing medical images and pores and skin biopsies. Twenty-seven p.c confirmed ‘good to glorious’ enchancment and the remaining 63% confirmed varied levels of enchancment. Pores and skin biopsy confirmed that each epidermal and dermal thickness elevated in addition to the immunoreactivity of procollagen kind 17. Curiously, the lesions which responded the perfect have been SA, on condition that SA is normally extra recalcitrant to therapy than SR as a result of maturity of the striae; nevertheless, discount in vascularity was not an end result measure.

Park et al. carried out a pilot research on 16 sufferers with both SA or SR wherein they acquired three remedies of microneedling, each Four weeks. Outcomes have been assessed utilizing a quartile grading scale and 43.8% demonstrated marked to glorious enchancment and general 37.5% of sufferers have been extremely glad, 50% considerably glad, and 12.5% unhappy8.

Comparative research

Gokalp in contrast the result of SR and SA utilizing the 1550 nm non-ablative fractional laser in pregnancy-induced SD in 16 girls. Every candidate had 5 periods at 4-weekly intervals. It was discovered that general strial width and size lowered at one month and one-year post-treatment respectively9.

A comparative split-striae research evaluating two completely different settings of long-pulsed Nd:YAG laser to deal with each SR (N=23) and SA (N=22) utilizing 75 versus 100 J/cm2 was carried out. A big enchancment was present in SA handled with 100J/cm2, whereas a higher enchancment was present in therapy with 75 J/cm2 within the SR section of the research. Once more, each collagen and elastin elevated histologically publish therapy10.

El Taieb and Ibrahim in contrast fractional CO2 laser versus IPL in 40 sufferers with SD. Each remedies modalities confirmed important enchancment, with fractional CO2 laser displaying enchancment prior to IPL — outcomes evident after 5 periods versus ten periods with IPL11.

Shut-up of feminine hips with a stretch marks throughout laser elimination session therapy

A potential, randomized, comparative trial with fractionated bipolar radiofrequency and bipolar radiofrequency along side infrared mild to deal with SD on the stomach of 22 sufferers (with a complete of 384 SR and SA) was carried out. Outcomes demonstrated that imply striae depth lowered by 21.64% six months post-treatment within the mixture group versus a rise of 1.73% within the management group. Histological overview post-treatment demonstrated thicker collagen fibres within the non-control group12.

An fascinating comparative research evaluating microneedling remedy with a fractional CO2 laser within the therapy of SD in 20 Egyptian feminine sufferers discovered microneedling to be extra helpful with 90% of sufferers displaying medical enchancment versus solely 50% within the CO2 laser group13.

Wang et al. in contrast two completely different wavelengths of non-ablative lasers (1540 nm and 1410 nm) within the therapy of SD in a split-abdomen research involving six sufferers. Each medical enchancment (based mostly on images) and histological enchancment from pores and skin biopsy have been present in every group, with no statistical variations. Pores and skin biopsy demonstrated elevated epidermal and dermal thickness, elevated collagen and elastin density compared to pre-treatment biopsies14.

A research evaluating the long-pulsed Nd:YAG 1064 nm versus the 2940 nm tunable pulse width Er:YAG was carried out in 22 sufferers (SR=3, SA=17). Each Remedy sorts have been randomly allotted to each side of the physique, and all topics have been handled weekly for a complete of three periods. Sufferers with SA lesions have been discovered to have a poor response to therapy on photographic overview of therapy, whereas sufferers with SR had reasonable responses (on each side). Curiously, though medical end result was poor in each teams, histological enchancment was nonetheless famous post-treatment, in all samples, compared to pre-treatment pores and skin biopsies15.

A randomized, managed trial evaluating two modalities of fractional lasers (ablative CO2 versus non-ablative 1550 nm Er:Glass) in a split-abdomen research on 24 sufferers confirmed no important distinction between the 2 teams (three remedies in whole 4-weekly) regardless of each teams displaying medical and histological enchancment16.

The usage of PDL for each SR and SA in 22 sufferers demonstrated a reasonable enchancment within the erythema of SR with little change in SA17.

Mixture research

A research evaluating the mixture of fractional CO2 with PDL versus fractional CO2 alone within the therapy of 88 SA lesions of three feminine sufferers confirmed the mixture therapy to be simpler with a major higher discount in post-treatment floor space (P=0.03) and a considerably greater VAS rating (P<0.001)18.

Ryu et al. reviewed mixture remedy with fractionated microneedle radiofrequency (RF) and fractional CO2 laser in SD on 30 sufferers with reasonable to extreme striae. A 3rd have been handled with fractional CO2 laser solely, a 3rd with microneedle RF solely, and the ultimate third used a mix of each remedies. Imply enchancment utilizing VAS have been 2.2, 1.8, and three.Four respectively. Histology demonstrated thickened dermis and better variety of collagen fibres within the mixture handled websites19.

Naein and Soghrati carried out a managed trial on 92 sufferers with SD, evaluating fractional CO2 laser in group one (5 periods of laser, 2–Four weekly intervals) with group two, who have been handled with 10% glycolic acid plus 0.05% tretinoin cream at evening during the research. Group one confirmed a considerably lowered floor space of SD in contrast with group two, and the imply VAS was greater in group one. Though, no statistically important distinction was famous20.

Suh et al. reviewed the result of treating stomach SD in 37 Asian sufferers, initially with RF together with PDL, after which with two subsequent periods of PDL at Four and eight weeks. Subjective evaluation demonstrated 89.2% of sufferers confirmed ‘good and superb’ general enchancment and 59.4% demonstrated ‘good and superb’ enchancment with reference to elasticity, with the authors deducing RF with PDL an general efficient therapy21.

One other research amongst 19 Asian sufferers used the mixture of intradermal RF mixed with autologous PRP, at 4-weekly intervals for a complete of three periods. Just one affected person had a superb enchancment, seven had marked enchancment, six had reasonable enchancment, and 5 gentle enchancment. None had a worse end result and 63.2% of sufferers have been glad to very glad22.

A research taking a look at comparability between two completely different mixtures of topical remedy in SD (20% glycolic acid/0.05% tretinoin versus 20% glycolic acid/10% L-ascorbic acid) in 10 sufferers, whereby they handled half of the realm with every therapy subset every day for 12 weeks, discovered each mixtures improved the looks of SD in addition to enhance epidermal thickness and reduce papillary dermal thickness compared to untreated SD23.

Dialogue

Though quite a few makes an attempt have been made to enhance the medical look of SD, no ‘gold normal’ modality has emerged to this point that persistently restores SD fully.

When it comes to topical brokers, tretinoin and glycolic acid have been proven to provide good outcomes in opposition to the looks of current SD. These remedies, nevertheless, supply little to no profit in opposition to mature SD. The usage of energy-based therapy strategies, typically together, has been proven to supply medical enchancment as a result of reorganization of the collagen and dermal remodelling.

The CO2 laser was discovered to be the modality with essentially the most obtainable proof (six RCTs, three non-randomized managed research, and one observational research). RF was discovered to be essentially the most steadily employed modality (11 research), adopted by the CO2 and pulsed dye lasers (10 and 5 research, respectively).

Non-ablative fractional lasers have demonstrated discount in each size and width of SD; nevertheless, the longest follow-up documented is that of 1-year post-treatment. Even when outcomes haven’t been clinically helpful, the histology has virtually all the time demonstrated a rise in collagen elastin bundles from pre- and post-treatment pores and skin biopsies highlighting the potential discrepancy between medical and histological enchancment.

Importantly, it’s virtually inconceivable to check therapy outcomes between the research offered. That is partly as a result of every laser research might use a unique variety of remedies, with completely different intervals and completely different fluencies (excessive versus low), added to the distinction in end result measurements methodology, which was inconsistent in research. Some research used subjective measurement from the affected person, others medical images with impartial/blinded assessors or VAS scores.

Acknowledgements

  Declaration of curiosity None

References

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