Treatment of striae distensae: An evidence-based approach

Comparing Energy-Based Devices for Striae Improvement: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Striae distensae (SD) are cutaneous lesions that are caused by hormones or mechanical stress leading to rapid expansion of skin. Therefore, SD are now a cosmetic concern. However, improving SD is notoriously difficult. Among different treatments, energy-based devices (EBDs) are much more effective and controllable.

OBJECTIVE

The aim of this review was to determine the most effective type of EBD for improving the appearance of striae.

MATERIALS AND METHODS

The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The population comprised patients suffering from striae. Different types of EBDs used to improve striae were compared. The primary outcome of the reduction in the width of striae was evaluated. A random-effects model was performed. The means and standard deviations were extracted.

RESULTS

Eighteen randomized controlled trials were included. The network meta-analysis revealed that after a comparison among the 4 types of EBDs, no significant differences were observed in the reduction of striae width.

CONCLUSION

Radiofrequency, ablative lasers, nonablative lasers, and intense pulsed light are all effective treatments for reducing the striae width. None of them was superior to the others. However, radiofrequency and ablative lasers may have the highest chance of improving the appearance of striae.

A Systematic Review on Treatment Outcomes of Striae

BACKGROUND

Striae are fine lines on the body that occur following rapid skin stretching (i.e., following pregnancy, puberty, weight change). The aim of this systematic review was to assess the current literature on treatment outcomes associated with striae.

OBJECTIVE

(1) To assess the efficacy and safety of different treatment options reported for striae and (2) to determine the most efficient treatment options for each subtype of striae.

METHODS

A systematic search was performed on MEDLINE, Embase, and PubMed with no publication date or language restrictions. All articles with original data and treatment outcomes were included.

RESULTS

One hundred fifty-one studies on the treatment of striae met inclusion criteria (83% female, mean age at diagnosis = 30.2), and 4,806 treatment outcomes of striae were described. Energy-based devices were the most reported modality (56%; n = 2,699/4,806), followed by topicals (19%; n = 919/4,806) and combinations (12%; n = 567/4,806). The highest rates of complete response were injection-based devices for striae distensae (7%; n = 12/172), CO 2 lasers for striae alba (4%; n = 12/341), and platelet-rich plasma injections for striae rubra (31%; n = 4/13).

CONCLUSION

Treatment options for striae are varied, likely indicating a lack of effective treatments due to the diversity in striae subtypes. Improved outcomes in striae management may be achieved with additional research on factors that predict treatment response.

Efficacy and Safety of an Autologous Micrografting Procedure for Management of Striae Distensae in Women

INTRODUCTION

Striae distensae (SD), or stretch marks, are a common skin problem having a psychological impact and cosmetic concern, especially for women, in whom the prevalence is higher than in men. This study assessed the efficacy and safety of a single autologous micrografting treatment (AMT®) using Rigenera® technology for the management of SD.

METHODS

This single-centre study included 10 healthy women between 24 and 65 years of age, with Fitzpatrick-Goldman skin types I-IV, who had visible SD in glutes/thighs. Each subject acted as their own control. The treatment procedure (microneedling + AMT) and the control procedure (no treatment) were performed on contralateral sides of the glutes/thighs, targeting matched and paired SD. Microneedling was carried out using Dermapen®, equipped with 32 needle heads set at 1.5 mm needle length. The AMT procedure involved extracting biopsies from the mastoid hair zone with a 2.5-mm dermal punch, followed by disaggregation of the biopsies in a physiological saline solution using the Rigeneracons. The disaggregated micrografts were then intradermally injected using 30G 4-mm needles, maintaining a distance of 1 cm between injection points, covering the entire marked treatment region.

RESULTS

In the treated area, at 3 months post-procedure compared to pre-procedure, the following changes were observed, all with statistical significance (P ≤ 0.05): (a) significant reductions in skin roughness (Ra, - 15.9%; Rz, - 22.6%), skin luminance (- 2.0%), and blue-green color distribution (- 10.6%); (b) significant increases in skin microcirculation maximum value (+ 240.1%), skin hydration (+ 71.2%), skin elasticity (+ 216.5%), skin density (+ 34.3%), skin thickness (+ 26.0%), and hypodermis thickness (+ 29.9%). Furthermore, for each of the aforementioned parameters, there was a significantly greater improvement observed with the AMT procedure compared with microneedling at 3 months (all P ≤ 0.05).

CONCLUSION

The AMT procedure using Rigenera technology resulted in an noticeable improvement in the SD appearance after 3 months in healthy women.

Combined Fractional CO 2 Laser With Intradermal Platelet-Rich Plasma versus Fractional CO 2 Laser Alone in the Treatment of Striae Distensae

BACKGROUND

Striae distensae (SD) or stretch marks are common cutaneous conditions that occur because of the stretching of the dermis.OBJECTIVE To evaluate and compare the efficacy of fractional carbon dioxide (CO 2 ) laser alone versus combined fractional CO 2 laser with platelet-rich plasma (PRP) in SD treatment.

METHODS AND MATERIALS

Thirty adult female patients with SD (SR and SA) were enrolled. In each patient, a split-lesion design was conducted as follows: pairs of SD on both sides of the midline were selected and allocated to groups A and B. Group A: was treated with combined fractional CO 2 laser with intradermal PRP. Group B: was treated with fractional CO 2 laser alone. Skin biopsies were taken from the lesions before and after treatment for histopathologic evaluation.

RESULTS

In group A, a significant excellent improvement of the SD was achieved more than in group B ( p = .007) and the mean of improvement was significantly higher (60.33 ± 26.49) than that in group B (43.80 ± 27.43) ( p -value = .001). Group A was also associated with a more significant dermal deposition of collagen and elastic fibers.

CONCLUSION

Combined fractional CO 2 laser with PRP was more effective than fractional CO 2 laser alone for the treatment of SD.

Striae Distensae: Clinical Results and Evidence-Based Evaluation of a Novel 675 nm Laser Wavelength

Background: A current popular aesthetic problem, especially among younger women, is striae distensae (SD), also referred to as "stretch marks.". Aim: The potential use of the 675 nm laser has been investigated in the treatment of SD. Methods: Patients underwent three sessions of the 675 nm laser with a 1-month interval between sessions. A total of three sessions were performed. The Manchester Scar Scale was used to assess stretch mark changes, and the mean scores related to each parameter at baseline and 6M FU after the last treatment session were measured. A clinical photographic evaluation was performed to show the aesthetic improvement of SD. Results: The patients' treated areas were the abdomen, thighs, buttocks, and breasts. Mean scores related to each Manchester Scar Scale parameter, with their relative percentage change, at baseline and 6M FU after the last treatment session were significantly improved. The total mean Manchester Scar Scale score significantly diminished from 14.16 (±1.30) to 10.06 (±1.32) at 6M FU (p < 0.01). The clinical photographs showed promising aesthetic SD improvement. Conclusions: 675 nm laser therapy demonstrated a good tolerance for the treatment of stretch marks applied to various body areas preventing any discomfort for the patient and with a significant improvement in skin texture.

Hypertrophic Scars and Keloids: Advances in Treatment and Review of Established Therapies

Hypertrophic scars and keloids can have significant detrimental effects on patients both psychosocially and functionally. A careful identification of patient risk factors and a comprehensive management plan are necessary to optimize outcomes. Patients with a history of dystrophic scarring should avoid unnecessary procedures and enhance the wound-healing process using various preventive strategies. As there is no single, fully efficacious treatment modality, prevention remains the best approach in reducing aberrant scar formation. When prevention therapies fail, keloids have been shown to be respond to a variety of therapies including topical and injectable corticosteroids, 5-fluorouracil, radiotherapy, lasers, and surgical excision, all with varying efficacies. As such, management should be tailored to the individual patient's risk factors with the use of combination therapies to reduce recurrence rates. Still, keloid and hypertrophic scar therapies are widely diverse with novel treatment modalities providing alternatives for recurring lesions. Laser-assisted drug delivery, skin priming, and novel topical therapies may provide alternative options for the management of hypertrophic scars and keloids.

The efficacy and safety of the innovative cold atmospheric-pressure plasma technology in the treatment of striae distensae: A randomized controlled trial

BACKGROUND

Available current therapeutics modalities for striae distensae (SD) provide inconsistently effective outcomes. There is ongoing research on innovative treatment modalities to find better treatment solutions.

OBJECTIVES

To evaluate the efficacy and safety of innovative cold atmospheric plasma (CAP) technology in the treatment of striae distensae.

METHODS

This study includes twenty-three patients with striae distensae. The body was divided into two halves. One side was randomly treated with CAP biweekly on the same treated side for five sessions with 30 days follow-up after the last session. Another half was left untreated. Efficacy assessment was done using patient and observer scar assessment scale (POSAS), patient satisfaction scales, and Antera 3D® skin imaging system. Safety assessment was evaluated using the visual analog scale (VAS) and adverse effects monitoring.

RESULTS

Patient and observer scar assessment scale, patient and observer overall opinion score, and patient and observer total score in a summary of all rated characteristics, comparing treated and untreated areas, showed a statistically significant reduction in all parameters after one treatment (*p-value <0.05). Patients rated satisfaction as a great improvement in 52.3%, moderate improvement in 39.1%, extreme improvement in 4.3%, and slight improvement in 4.3%. Adverse effects included small scabs, shallow wounds, and rash.

CONCLUSION

Cold atmospheric plasma is a safe and effective, innovative treatment modality for striae distensae with minimal side effects.

Fractional CO2 Laser versus Fractional Radiofrequency for Skin Striae Treatment: Study Protocol for a Randomized Controlled Trial

Striae are common dermal lesions associated with physiological and psychological alterations, affecting the quality of life. This proposed randomized controlled trial protocol will evaluate the clinical efficacy and treatment safety of fractional CO₂ laser versus fractional radiofrequency (FRF) in clinical trials. We will randomly allocate 60 subjects who present abdominal striae into two different groups for the treatment, which will be performed once a month for a 3-month period. The results will be assessed by quartile scoring criteria; by comparing digital photos taken before and after each treatment; and also, by the measurement of cutaneous temperature, skin pH, and elasticity before and after the treatment. This paper describes the rationale and the design of the randomized controlled trial, which may provide evidence for clinical application of the methodology and the quality related to the efficacy and safety of fractional CO₂ laser versus the FRF protocol for striae treatment.

Striae distensae as a diagnostic indicator for eating disorder pathologies

OBJECTIVE

This manuscript provides a review of the relationship between patients with an underlying eating disorder (ED) and the presence of striae distensae (SD). Researchers and clinicians have recognized many different skin manifestations associated with EDs. According to the Diagnostic and Statistical Manual of Mental Disorders, EDs include, but are not limited to, anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). The presence of specific skin findings often helps clinicians conclude whether or not a patient may have an underlying ED and require further evaluation. One skin finding associated with an ED with little current literature focus is SD. SD arises from a combination of hormonal imbalances and stretching of the dermis, triggering a local inflammatory response. The presence of SD leaves patients with diminished quality of life. There is no single guideline treatment for SD; however, topical and/or light and laser therapies can be utilized.

METHOD

Using online medical literature databases and the PRISMA guidelines, 11 out of 574 articles met the acceptable criteria to be analyzed, emphasizing the lack of current literature on this subject.

RESULTS

Anxiety and depression were comorbidities demonstrated to be strongly related to AN and obesity, secondary to BED, in patients who developed SD. Higher degrees of suicidal ideation and insomnia, along with lower self-esteem levels, were more likely to be present in these patients.

CONCLUSION

Altogether, this review highlights the importance of continued evaluation of SD and its overall impact on patient's mental health, emphasizing an underlying ED.

Comparison of the efficacy of microneedling versus CO2 fractional laser to treat striae alba: A randomized clinical trial

Striae distensae (SD) are common skin conditions that have posed a significant challenge regarding their assessment and treatment. The present study aimed to evaluate the efficacy of microneedling in comparison to fractional CO₂ laser therapy. Similar striae were selected and photographed. Each side was randomly assigned to be treated with CO₂ fractional laser or microneedling four times at monthly intervals and followed up for 10 months. Outcome measures including the length and width of the largest striae, dermatologist assessed improvement, patients' satisfaction, and visual analog scale (VAS) were assessed. Wilcoxon signed-rank test and Mann-Whitney U test were used to assess the efficacy of treatments. Forty patients with a mean age of 28.1 years were included. The median cross-section of the largest striae decreased significantly in both groups (P-value <0.001), without statistically significant differences between the two groups before and 6 months after treatment. VAS also improved significantly in both groups, and there were no statistically significant differences between the two treatments in all visits. No clinically significant adverse effects were observed. Fractional CO₂ laser and microneedling are both efficient treatments to resolve SD. A new light should be shed on the microneedling modality as it is more economical than the other treatment options.

Topical oil formulation of plant extracts and vitamins as effective treatment for stretch marks and xerosis-An observational longitudinal study

Background

Stretch marks are linear scars that result from elastic fiber destruction. They usually occur as the consequence of rapid change in the body mass (weight gain and loss, pregnancy, weightlifting), long‐term steroid use, or endocrinopathies. Treatment is challenging and mainly based on topical and procedural therapies, although the standard of care is still under debate.

Purpose

To evaluate the efficacy and tolerance of a topical oil formulation of plant extracts and vitamins on the aesthetic improvement of stretch marks and xerosis.

Materials and methods

Fifty male and female patients, aged between 14 and 45 years, with stretch marks referring at the University Hospital Federico II, Naples, were enrolled between March and November 2019. Topical application of plant extracts and vitamin‐rich oil was performed twice daily on affected skin for 4 months. Patients were monitored at baseline (T0), and at two‐month (T1) and 4‐month (T2) follow‐ups, through clinical and dermoscopic assessment, confocal microscopy, cutaneous ultrasound, MoistureMeterEpiD, and X‐Rite spectrocolorimeter. Primary endpoints were as follows: 70% clinical improvement of stretch marks and 3‐point decrease in clinical score from baseline to T2. Secondary endpoints were as follows: change in the T0 parallel pattern of collagen fibers at confocal microscopy, cutaneous thickness increase at ultrasounds, cutaneous hydration increase at MoistureMeterEpiD, erythema reduction at X‐Rite spectrocolorimeter, and safety and adverse events (AEs).

Results

At 4‐month follow‐up, stretch marks improved objectively and subjectively in all patients (p < 0.001). In detail, there was a 29% and 71% improvement in clinical appearance of stretch marks at T1 and T2, respectively, as documented dermoscopically and by the 3‐point reduction in the assessor's mean clinical score at each follow‐up visits [from 8.1±0.7 at baseline to 5.7±1.0 at T1 and 2.3 ±0.5 at T2 (p < 0.001)]. Erythema decreased by 15% and 30% and in parallel hydration increased by 25% and 71%, at T1 and T2, respectively (p < 0.001). At T2 confocal microscopy of stretch marks, dermal collagenous fibers assumed casual disposition with reticular pattern and refractivity, as signs of collagen remodeling and neocollagenesis, and also the T2 cutaneous ultrasound revealed increased epidermal thickness and decreased dermal hypoechogenicity as for a higher skin hydration.

Conclusion

Our study showed that a topical oil formulation rich in plant extracts and vitamins appears to be effective and safe in treating stretch marks and xerosis.

Efficacy of platelet-poor plasma gel in combination with fractional CO2 laser in striae distensae: A clinical, histological, and immunohistochemical study

BACKGROUND

Platelet-poor plasma gel is a semi-solid plasma formulation that recently recommended as autologous bio-filler for treatment of atrophic dermal scars.

AIM

To compare the therapeutic efficacy and safety of intradermal injection of plasma gel in combination with fractional CO₂ laser versus fractional CO₂ laser alone in striae distensae (SD).

PATIENTS AND METHODS

This study included 36 SD patients treated by three sessions (one session/1.5 months) of fractional CO₂ laser on all SD lesions following intradermal injection of plasma gel on one side and saline (as placebo) on the other side.

RESULTS

Significant clinical improvements associated with remarkable narrowing of SD lesions and prominent enhancement of skin texture were observed on both treatment sides. Obviously, higher degrees of clinical improvements of SD lesions were reported following combined therapy with fractional CO₂ laser and plasma gel rather than fractional CO₂ laser monotherapy. However, post-inflammatory hyperpigmentation (PIH) was reported more frequently with fractional CO₂ laser monotherapy. Histopathological and immunohistochemical examinations revealed significant epidermal improvement, and homogenization, and orientation of dermal collagen bundles as a result of both therapeutic procedures.

CONCLUSION

Plasma gel in combination with fractional CO₂ laser could be considered a promising novel treatment modality for SD. Plasma gel not only improves the efficacy of fractional CO₂ laser but also decreases the frequency of PIH.

Development of a clinical scale to assess the severity of striae distensae

BACKGROUND AND OBJECTIVE

There is no validated instrument to assess the clinical severity of striae distensae. Here, we aimed to develop a striae distensae severity scale.

MATERIAL AND METHODS

After a Delphi-based consensus, 15 items related to striae severity were assessed in 110 areas (breasts, abdomen, and buttocks) from 45 participants. The items were analyzed through a partial least squares model to select the most important variables. To assess the reliability of the scale, 43 areas were retested.

RESULTS

Of the 110 areas evaluated, 34 were breasts, 24 abdomens, and 52 buttocks. Striae were considered mild in 30% of the evaluations, moderate in 33%, severe in 21%, and extremely severe in 16%. The final model was composed by: width of the widest striae, width of the striae with the most frequent pattern, atrophy, number of affected quadrants, distribution (multiple or isolated), hypo or hyperchromia and topography. The scores of the scale demonstrated a high correlation with the clinical classification (rho = 0.77). There was a high agreement in the scores from the reassessed areas (intraclass correlation coefficient = 0.90).

CONCLUSION

An objective and reliable scale to assess the clinical severity of striae distensae on the breasts, abdomen, and buttocks was developed.

Comparative effectiveness of different therapies for treating striae distensae: A systematic review and network meta-analysis

BACKGROUND

Striae distensae (SD) are common and aesthetically undesirable dermal lesions. The aim of this study is to comprehensively evaluate the effectiveness of different therapies in treating striae distensae using network meta-analysis.

METHODS

A systematic search of electronic databases up to December 1, 2019 was conducted. Randomized controlled trails (RCTs) examining the effectiveness of different methods in treating striae distensae were included. The primary outcomes are clinical effective rate and patient's satisfaction degree. Risk of bias was assessed by the Cochrane risk of bias tool. Network meta-analysis was based on Bayesian framework.

RESULTS

Fourteen trails that met the criteria with 651 subjects were included. The results of the network meta-analysis show that topical tretinoin combined bipolar radiofrequency showed the highest probability of being the best method to improve the clinical effectiveness and patient satisfaction rate of treating SD (84.5% and 95.7% respectively), closely followed by bipolar radiofrequency (75.3% and 84.3% respectively). Among laser treatment, CO2 fractional laser is superior to other lasers in the clinical effectiveness and patient satisfaction (72.0% and 58.1% respectively). Statistics showed the topical tretinoin was the worst-performing option in improving the clinical effectiveness and patient satisfaction rate of SD treatment (5.4% and 5.1% respectively).

CONCLUSION

Based on the results of network meta-analysis, we recommend treating striae distensae with bipolar radio frequency combined topical tretinoin. The commonly used CO2 fractional laser can be considered as alternative treatment candidate. Additional large-scale RCTs are necessary to obtain more precise estimates of their relative efficacy.