para>During puberty, SD appear in areas that rapidly increase in size.
Pregnancy Considerations
Common finding on the abdomen, breast, and thighs of pregnant women, especially during the 3rd trimester " called striae gravidarum
EPIDEMIOLOGY
Incidence
Incidence range of 43 " 88% for women during pregnancy (1)
Prevalence
- Adult nonpregnant female: 35%
- Adult males: 11%
- Adolescent females: 72 " 77%
- Adolescent males: 6 " 86%
ETIOLOGY AND PATHOPHYSIOLOGY
- Specific etiology of SD is unknown.
- Three main theories are proposed as likely contributing to SD formation: mechanical stretching, hormonal changes, and innate structural disturbance of the skin (1).
- Mechanical stretching theorized to cause rupture of connective tissue framework.
- Hormonal alterations in levels of adrenocorticotropic hormones, cortisol, and relaxin are most related to development of SD (1).
- Adrenocorticotropic hormones and cortisol are thought to promote fibroblast activity causing destruction and alterations of collagen and elastin fibers (1).
- Women who develop SD during pregnancy were found to have increased estrogen and androgen receptors in their skin, and had lower measured serum relaxin levels than control groups who did not develop SD (1).
- Innate structural defects whether genetic or transient cause disruptions in the elastic fiber integrity of the skin. Generally, conditions with decreased relaxin and collagen content as well as reduced expression of procollagen and fibronectin genes are associated with higher prevalence of SD (1).
- In striae rubra, inflammatory changes predominate; dermal alterations visible on transmission electron microscopy include mast cell degranulation and macrophage activation leading to elastolysis in the mid-dermis (1).
- In striae alba, histologic findings include epidermal atrophy; thin, eosinophilic collagen bundles arranged horizontally, which is parallel to surface of the skin as is seen in other scar formation (1).
- Skin samples from SD can have marked reduction in visible elastin content compared to adjacent normal dermis, as well as decrease in fibrillin content (1).
- This reorganization of fibrillin and elastin after a possible insult to the skin are thought to play a critical role in pathogenesis of SD (1).
Genetics
Genetic predisposition is noted with positive monozygotic twin studies and multiple genetic connective tissue disorders.
RISK FACTORS
- Pregnancy, specifically young maternal age, large birth weight, later gestational age, increased weight gain during pregnancy, and polyhydramnios
- Positive family history
- BMI >27
COMMONLY ASSOCIATED CONDITIONS
- Connective tissue disorders: Marfan syndrome and Ehlers-Danlos syndrome
- Immunosuppression states: HIV, TB, and typhoid
- Other medical conditions: Cushing syndrome, rheumatic fever, anorexia nervosa, chronic liver disease, obesity
- Surgery: breast augmentation, tissue-expanded skin, organ transplantation (immunosuppressed state), and cardiac surgery
- Medications: systemic and topical corticosteroids, HIV therapy, chemotherapy, TB therapy, contraceptives, and neuroleptics
- Other: pregnancy, puberty, and weight training
DIAGNOSIS
PHYSICAL EXAM
- Universal classification system or process for evaluating severity of SD is not currently established. The Davey Score (scale 0 to 8 given based on number of lesion on abdomen) or Atwal Score (scale 0 to 24 given based on intensity of lesions on abdomen, breasts, hips, and thighs/buttocks) have been used to aide in assigning objective data for research purposes but not universally used (1).
- Diagnosis typically made based on clinical features consistent with either striae rubra or striae alba. Use of 3D cameras, reflectance confocal microscopy, dermoscopy, and epiluminescence colorimetry may be tools for objective evaluation, but no validation studies have been completed to date.
- Striae rubra are typical initial finding characterized as erythematous to violaceous, raised linear lesions along specific areas of distribution related to age and sex.
- Adolescent males: develop SD primarily along the buttocks, lower back, and knees (in descending order of prevalence)
- Adolescent females: develop SD primarily along the buttocks, thighs, and calves
- During pregnancy, development of SD is primarily along the abdomen, breasts, and thighs.
- Other medical, surgical, and medication-related SD lesions can have varied areas of distribution.
- Striae alba develop secondarily appearing as atrophic, hypopigmented, finely wrinkled lesions, which are the chronic presentation of SD.
DIFFERENTIAL DIAGNOSIS
Linear focal elastosis (elastotic striae)
TREATMENT
GENERAL MEASURES
- In current practice, there is not an available treatment modality that is consistently effective with minimal adverse effects.
- Avoidance of rapid weight loss or gain may help prevent the emergence of stretch marks.
- Fitzpatrick skin type and stage of striae should be taken into consideration when treating, darker skin, Fitzpatrick types III to VI, are particularly at risk for adverse outcomes from use of laser treatments (1)[A].
- No consistent evidence to support use of any currently available topical treatments for prevention of pregnancy-related stretch marks (2)[A]. However, small isolated studies noted benefit with Trofolastin versus placebo, hyaluronic acid, and use of almond oil with massage versus almond oil alone or placebo. No benefit in any study with use of cocoa butter (1)[A].
MEDICATION
First Line
0.1% tretinoin cream daily for 6 months has been shown to improve the clinical appearance of striae during the active stage (striae rubra) but not during mature stage (striae alba) (1)[A].
ALERT
Topical tretinoin is pregnancy Category C and should not be used in pregnant or breastfeeding women due to theoretical teratogenic effects.
Second Line
See "Surgery/Other Procedures. "
SURGERY/OTHER PROCEDURES
- 585-nm flashlamp-pulsed-dye laser (PDL) noted effectiveness in treating SD in skin types II to IV; types V and VI should avoid this treatment due to possible pigment alterations (1)[A].
- 308-nm xenon chloride excimer laser used for striae alba has shown repigmentation but requires maintenance treatments approximately once every 1 to 4 months (1)[A].
- Fractional photothermolysis via fractional CO2 laser seems to be an effective method for treating striae in skin types III and IV (3)[A] but can cause erythema and hyperpigmentation in skin types IV to VI (1)[A].
- Intense pulsed light (IPL) studies have demonstrated some decrease in number and size of SD lesions, by process of organizing collagen fibers, but require repeat sessions to maintain effects (1)[A].
- Microdermabrasion treatment noted significant improvement in striae rubrae with similar efficacy to topical tretinoin cream but with lower frequency of side effects and better adherence to treatment. It is a safe, fast, and low-cost treatment option that can be used during pregnancy (4,5)[C].
COMPLEMENTARY & ALTERNATIVE MEDICINE
- Hydrant creams are numerous and unproven for treatment; more studies are needed to determine the efficacy and safety of these products.
- Glycolic acids (GA) noted possible clinical improvement of SD in small trials (1)[A].
- Trichloroacetic acid (TCA) noted possible clinical improvement in multiple case series studies (1)[A].
- Possible benefit from percutaneous collagen induction and needling, but further studies are needed (1)
ONGOING CARE
DIET
Further studies are needed to establish a clear effect of diet and exercise on SD development.
REFERENCES
11 Al-Himdani S, Ud-Din S, Gilmore S, et al. Striae distensae: a comprehensive review and evidence-based evaluation of prophylaxis and treatment. Br J Dermatol. 2014;170(3):527 " 547.22 Brennan M, Young G, Devane D. Topical preparations for preventing stretch marks in pregnancy. Cochrane Database Syst Rev. 2012;(11):CD000066.33 Naein FF, Soghrati M. Fractional CO2 laser as an effective modality in treatment of striae alba in skin types III and IV. J Res Med Sci. 2012;17(10):928 " 933.44 Hexsel D, Soirefmann M, Porto MD, et al. Superficial dermabrasion versus topical tretinoin on early striae distensae: a randomized, pilot study. Dermatol Surg. 2014;40(5):537 " 544.55 Hexsel D, Dal 'Forno T, Mazzuco R. Superficial dermabrasion in the treatment of recent stretch marks (striae rubra). J Am Acad Dermatol. 2009;60(3):186.
ADDITIONAL READING
- Elsaie ML, Baumann LS, Elsaaiee LT. Striae distensae (stretch marks) and different modalities of therapy: an update. Dermatol Surg. 2009;35(4):563 " 573.
- McDaniel DH. Laser therapy of stretch marks. Dermatol Clin. 2002;20(1):67 " 76.
CODES
ICD10
L90.6 Striae atrophicae
ICD9
701.3 Striae atrophicae
SNOMED
- physiological striae (disorder)
- Striae gravidarum (disorder)
CLINICAL PEARLS
- SD is a common skin condition usually consisting of multiple, symmetric, well-defined atrophic lesions that follow the lines of tension.
- Initially appear as red elevated lines (striae rubra), over time with atrophy change and fade to a fine, white appearance (striae alba)
- In current practice, total resolution of SD remains unattainable.
- 0.1% tretinoin cream daily for 6 months has been shown to improve the clinical appearance of striae if used during the active stage (striae rubra) (1)[A].