Treatment of striae distensae: An evidence-based approach

Striae distensae (SD), otherwise known as “stretchmarks,” are a common presenting complaint, particularly in young healthy women. SD are hypothesized to form in a patient when the cross-linked collagen is “overstretched” and rupture of this collagen matrix causes the striae. Thus, many treatments work by increasing collagen synthesis. This review critically appraises the evidence to date for the treatment of SD, including both energy-based devices and topical treatments.     

Galvano-puncture and dermabrasion for striae distensae: a randomized controlled trial

Objective: To assess the effects of galvano-puncture (GG) and dermabrasion (DG) in reducing striae distensae in the gluteal region of women. Methods: This randomized, controlled, single-blind clinical trial was conducted at the UNIFAL-MG. Participants were 48 female who had striae distensae alba in the gluteal region. They were randomly divided in GG; DG; and Control Group (CG). The length and width of the largest striae were measured (in millimeters) using a caliper. The same striae were assessed before and after treatment. Infrared thermography was performed in the gluteal region to assess local microcirculation. Results: Intragroup analysis showed a significant reduction in the dimension of the striae between baseline and treatment session 10 in the GG and DG groups. Between-group analysis revealed a reduction in the width and length of the striae for both the GG and DG groups, but there were no significant differences between the two groups. When compared to the CG and the DG group, the GG group had significant improvements, as shown by thermography. Conclusion: Both GG and DG are effective in reducing striae length and width. However, only the thermography results showed significant differences between GG and control, and between GG and DG.     

Efficacy of fractional carbon dioxide laser versus microneedling in the treatment of striae distensae

Background: Fractional photothermolysis is creation of microscopic thermal zones of controlled depth, width and density. Microneedling is a simple treatment modality to reduce striae distensae.

Objective: Evaluate and compare the efficacy of fractional carbon dioxide laser and microneedling as a treatment of striae distensae.

Methods: Individuals with striae distensae received three split-body treatments at four-week intervals. The right side of the body was treated with fractional CO₂ laser, while the other side with microneedling. Assessment was done by comparing photographs before and after treatments by two blinded physicians using a quartile grading scale. Evaluation also included patient satisfaction score and histopathological examination.

Results: In total 33 subjects were enrolled and 30 completed the study. By quartile grading score, we recorded 55% moderate-excellent improvement of striae in the dermaroller-treated side but with fractional CO₂ laser-treated side, we recorded 76% of patients had moderate-excellent improvement. Patients were more satisfied with fractional CO₂ laser than the microneedling. Post-inflammatory hyperpigmentation, as a complication of fractional CO₂ laser, appeared in 11 patients.

Conclusion: Fractional CO₂ laser is more effective in treating striae with acceptable side effects but still microneedling can be afforded as an effective, safe and cheap method.     

A case of edematous striae distensae in lupus nephritis

A 17-year-old girl with systemic lupus erythematosus presented with painful edematous abdominal striae. She had been treated with systemic steroid for the systemic lupus erythematosus. At the time of presentation, she had abruptly gained 10 kg due to combined lupus nephritis. The histopathologic finding of the edematous striae distensae included dermal edema with separation of collagen fibers and small fragmented elastic fibers. Edematous striae distensae are uncommon but can develop from the combined effects of glucocorticoid and generalized edema.     

Clinical features and risk factors for striae distensae in Korean adolescents

BACKGROUND: Despite the high prevalence of striae distensae, clinical studies are few in number, and their pathophysiology still obscure. OBJECTIVES: To determine the prevalence and clinical characteristics of striae distensae that occur in Korean adolescents, and to correlate their clinical features with family history, other dermatological conditions, and body measurements. METHODS: One hundred and fifty-seven healthy Korean students, aged 15 to 17, were studied. A questionnaire and physical examination were employed to assess the subjects' past and family history, and the distribution, clinical features and severity of striae distensae. RESULTS: Striae distensae were present in 131 subjects (83.4%). Ninety-four (88.2%) of 109 male and 37 (77.1%) of 48 female subjects were affected. The striae were white in colour in 69.5% and asymptomatic in most of the subjects. They developed at an average age of 13.8 years. Family history was present in 18 subjects (11.5%). Seborrhoea of the face was positively correlated (P < 0.035) with striae distensae, and atopic dermatitis negatively correlated (P < 0.001). In both sexes, the buttock was the most prevalent area of striae development, followed by the lower back and knee in boys and by the thigh and calf in girls. Striae were significantly more common on the thigh of girls and on the knee of boys. CONCLUSIONS: Our results indicate that striae distensae are a common skin condition that occurs early in puberty regardless of gender, and that they have a different anatomical distribution and relationship with body measurements in each gender.     

Treatment of striae distensae using fractional ablative CO2 laser in skin types II-IV: a retrospective case series study

Striae distensae (SD) are atrophic dermal scars often found on abdomen, breasts, thighs, and hips of pregnant women. The strias’ self-healing without any intervention is a poor possibility. Till now, several lasers and light sources have been used for treatment of SD. However, there are no integrated therapeutic approaches determined for treatment of SD yet. So, in this study, the therapeutic effect of fractional ablative CO₂ laser in women with pregnancy was assessed. Twenty-four ethic Iranian women aged between 20 and 42 years with various severity of pregnancy SD enrolled in retrospective case series study. Participants with skin types II-IV were treated in four sessions with a one-month interval by fractional ablative CO₂ laser. The severity of striae was determined by Daveys scoring. Clinical improvement was assessed by comparing pretreatment and posttreatment clinical photographs based on global improvement scoring. The evaluation of clinical results showed that fractional ablative CO₂ laser was an effective treatment. Twenty of 24 (83.3%) patients showed improvement. Clinical improvement was affected by striae severity (P = 0.03). Also, there were no statistical differences between clinical improvements with skin types, striae scar severity, number of pregnancy, and striae location.     

Measurement of mechanical forces generated by skin fibroblasts embedded in a three-dimensional collagen gel

Mechanical activities developed by cells play a significant role in the embryogenesis, development, and physiopathology of pluricellular organisms. A technique is described to measure in vitro the traction force developed by cells seeded into a three-dimensional polymeric collagen lattice. It is based on the use of strain gauges generating an electrical signal upon tension that is amplified and recorded. The intensity of the signal depends on the number and type of cells, cytoskeleton integrity, concentration of collagen in the lattice support, and fetal calf serum in the culture medium. Skin fibroblasts from humans and animals produce traction forces ranging from 100 to 1000 mg per million cells. In the gel under tension, the cells are in mechanical dynamic equilibrium with their support. It is suggested that the mechanical activity of fibroblasts and the control of the tension that they operate on the lattice support participate in the structural organization of the dermis and in its physiologic tension.     

Cell cycle analysis of human dermal fibroblasts cultured on or in hydrated type I collagen lattices

Summary The proliferation and cell cycle phase composition of human dermal fibroblasts cultured on or in type I collagen lattices (reconstituted dermis model) were examined. On collagen lattices, as compared with conventional cultures on plastic dishes, the proliferation of human dermal fibroblasts was suppressed, being arrested at about one-half the saturation density after 10 days of culture. In collagen lattices, proliferation was further suppressed, being nearly arrested within 4–7 days of culture. Cells were analyzed for cell cycle phases by two-color flow cytometry using DNA staining and S phase cell staining with FITC-conjugated antibromodeoxyuridine antibody. After 5 days of culture, the number of S phase cells on collagen lattices was 49.3% of that on plastic dishes, with an increase in G₀G₁ phase cells of 79.8%. In collagen lattices, the number of S phase cells was very small (4.3% of all cells), and most of the cells accumulated in G₀G₁ phase. These findings suggest that the cell cycle of fibroblasts is arrested at G₀G₁ phase by their interaction with collagen. On the basis of these results, the reconstituted dermis model using collagen lattice is considered to be analogous to the dermis in vivo with respect to cell growth and cell cycle phase composition.     

Stimulation of collagen expression and glycosaminoglycan synthesis by midkine in human skin fibroblasts

Midkine is a retinoid-inducible regulator of cell differentiation and cell growth in developing embryonic tissues. The effects of midkine on the expression of the extracellular matrix components, collagens and glycosaminoglycans, in dermal fibroblasts were studied. Midkine did not alter fibroblast proliferation. Collagen synthesis was stimulated in a dose- and exposure time-dependent manner and the maximum twofold stimulation was achieved at a concentration of 100 ng/ml for 72 h treatment. Midkine increased the synthesis of type I and III collagens to the same extent. Glycosaminoglycan synthesis was also stimulated twofold, mainly acounted for by an increase in hyaluronan synthesis. Midkine enhanced mRNA levels of α ₁ (I), α ₁ (III), α ₁ (VI) collagens, transforming growth factor β1 and matrix metalloprotease-2 but did not alter the mRNA levels of elastin, MMP-1 and tissue inhibitor of metalloproteases-1. These results suggest that midkine is a potent stimulator of collagen and glycosaminoglycan synthesis and may prove useful in the therapy of delayed wound healing. Received: 9 October 1996     

Contraction of collagen lattices by skin fibroblasts: drug-induced changes

Summary A range of dermatologically useful drugs were added to human skin fibroblasts cultured in collagen lattices to assess possible effects on the rate of lattice contraction. Vitamin C, Vitamin E, phenytoin, sodium salicylate, d-penicillamine and dibutyryl c-AMP had no significant effect. Chlorhexidine acetate at 10 g/ml arrested contraction after 24 h but this was related to its cytotoxicity. The antibiotics griseofulvin (2–16 g/ml) and cycloheximide (5–30 g/ml) caused dose-related inhibitions of contraction without affecting fibroblast viability. Four corticosteroids at 10 g/ml inhibited contraction, clobetasol propionate having the greatest effect. On the other hand 4 retinoids at 10^-5 M enhanced contraction by up to 20%. As lattice contraction appears to model the contraction of skin wounds and there are broad parallels between the effects shown here of antiseptics, corticosteroids and the retinoids, and their reported influence on healing wounds, the lattice system may be a useful pharmacological screen for new compounds.     

Melanoma cell-derived factors stimulate glycosaminoglycan synthesis by fibroblasts cultured as monolayers and within contracted collagen lattices

BACKGROUND: Various tumours exhibit glycosaminoglycan rich, and in particular hyaluronan rich matrices surrounding them that facilitate tumour growth and invasion. In many tumours, this matrix is predominantly synthesized by fibroblasts following stimulation by tumour cell-derived factors. OBJECTIVES: To determine what effect tumour cell-conditioned medium has upon fibroblast glycosaminoglycan synthesis when cells were cultured as monolayers and within contracted collagen lattices. METHODS: Serum-free conditioned medium from melanoma cell lines (C8161, MV3, A375 and Hs294T) was examined for its ability to stimulate the incorporation of 3H-glucosamine and 35SO4 into glycosaminoglycans synthesized by fibroblasts. RESULTS: Conditioned medium from all four melanoma cell lines exhibited potent glycosaminoglycan-stimulating activity. In monolayer culture, C8161-conditioned medium stimulated a 4.2-fold increase in fibroblast hyaluronan, and a 9.9-fold increase in sulphated glycosaminoglycan synthesis, while 35SO4 incorporation was increased only 2.1-fold. In collagen lattice cultures, C8161-conditioned medium stimulated a 4.9-fold increase in hyaluronan synthesis, a 5.4-fold increase in sulphated glycosaminoglycans, and a 1.3-fold increase in 35SO4 incorporation. CONCLUSIONS: Melanoma cells produce factors that are potent stimulators of fibroblast glycosaminoglycan synthesis, in both monolayer culture and within contracted collagen lattices. Synthesis of both hyaluronan and sulphated glycosaminoglycans with a reduced degree of polymer sulphation is stimulated. Such changes are likely to promote tumour cell proliferation and migration.     

Hexose sugars differentially alter collagen gene expression and synthesis in fibroblasts derived from granulation tissue,hypertrophic scar and keloid

Clinical observations have suggested that sugar and honey enhance granulation tissue formation and in vitro studies have shown that monosaccharide sugars stimulate mesenchymal and endothelial cells. In this study, the effects of glucose, fructose, galactose and mannose on type I and type III collagen gene expression and synthesis were studied in granulation tissue, hypertrophic scar and keloid fibroblast cultures. Glucose elevated both type I and type III collagen mRNAs in hypertrophic scar fibroblasts. Fructose increased type III collagen mRNA almost sevenfold in granulation tissue fibroblasts. Galactose caused an increase in type I and type III collagen mRNAs in granulation tissue fibroblasts and hypertrophic scar fibroblasts but, in contrast, mannose decreased type I and type III collagen levels in hypertrophic scar and keloid fibroblasts. Analysis of aminoterminal propeptides of type I and type III collagen (PINP and PIIINP) revealed that glucose decreased the amount of PINP in granulation tissue and keloid fibroblasts, whilst fructose decreased the amount in all the fibroblast cell lines studied. Galactose caused a decrease in the synthesis of type I collagen in all cell lines but a decrease was seen in type III collagen only in hypertrophic scar fibroblasts. Mannose decreased the amount of PINP in all cell lines but a decrease in the amount of PIIINP was seen only in granulation tissue fibroblasts. The effect of sugars on the ratio type I/type III collagen was negligible or decreasing with the exception of galactose, which increased the ratio in hypertrophic scar fibroblasts. The results suggest that glucose, fructose and galactose have no significant value in the stimulation of collagen synthesis in vitro. Mannose may have value in the prevention or treatment of abnormal scars.