Stretch Marks (Striae)


Article Author:
Amanda Oakley


Article Editor:
Bhupendra Patel


Editors In Chief:
Niamh Condon
Terry Tressler


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
12/28/2018 7:16:42 PM

Introduction

Striae, or stretch marks, are a common complaint and can be distressing. They may affect the abdomen, buttocks, thighs, breasts, back, axillae and groin. They are classified according to appearance or epidemiology, as:

  • striae atrophicans (thinned skin)
  • striae gravidarum (following pregnancy)
  • striae distensae (stretched skin)
  • striae rubrae (red), striae albae (white)
  • striae nigra (black)
  • striae caerulea (dark blue). 

Striae are difficult to treat effectively. [1][0]

Etiology

Striae are a form of dermal scarring associated with stretching of the dermis. They often result from a rapid change in weight (gain and loss) or are associated with endogenous or exogenous corticosteroids. Proposed mechanisms relate to hormones, physical stretch, and structural alterations of dermal collagen and elastic tissue. Adrenocorticotropic hormones promote fibroblast activity and increase protein catabolism. Pregnancy-related hormones may also contribute. Serum relaxin has been described to be lower in women with striae distensae.[3] Deficiency of fibrillin has also been proposed. [4] Genetic factors are unexplored, except that decreased expression of collagen and fibronectin genes is reported to be associated with striae.

Epidemiology

Striae distensae occur in pregnancy (43% to 88%), puberty (6% to 86%) and obesity (43%). Striae atrophicans follow medical conditions, particularly Cushing syndrome/disease, and treatments, usually exogenous topical or systemic corticosteroids [5], or surgery. Other associated diseases are Marfan syndrome[6], anorexia nervosa[7], various febrile illnesses, and chronic liver disease. Medications associated with striae also include chemotherapy, prolonged antibiotic therapy, contraceptives[8], and neuroleptics.

Striae are more common in females than in males and may be more common in certain races. They can appear more prominent in dark-skinned individuals. A positive family history is a risk factor for striae. During pregnancy, striae are more common in younger women than in older women. Several studies have noted greater prevalence with large abdominal circumference and large weight gain (due to fetal size or polyhydramnios). [0] One study reported that striae were more prevalent in smokers than non-smokers.

Pathophysiology

Pathophysiology is thought to involve elastases released from mast cells and macrophage activity. [10] Elastolysis of the mid-dermis is followed by a reorganization of collagen and fibrillin.

Histopathology of striae rubrae reveals excessive fine elastic fibers in the papillary dermis with thicker tortuous fibers in the periphery, with perivascular lymphocytes, dilated dermal vessels and edema. There are reduction and reorganization of elastin and fibrillin fibers, and structural changes in collagen fibers, which are thicker and densely packed in parallel rows. Histopathology of striae albae shows epidermal atrophy, loss of rete ridges, less vascularity, and densely packed, thin and scar-like horizontal collagen bundles.[4] They appear similar to mature atrophic scars.

Electron microscopy studies have also reported mast cell degranulation, macrophage activation, and elastolysis of mid dermis.[11]

History and Physical

History may explain the appearance of striae by association with stretched skin, for example, in pregnancy, pubertal growth spurt, muscular exercise, or weight gain. Inquire about topical application of potent corticosteroid or prolonged systemic steroids during the recent or remote past. If striae are widespread and none of these explanations are relevant, take a full medical history and conduct a thorough clinical examination.[0]

The initial striae rubrae are slightly raised pink or violaceous linear marks (striae rubrae), which fade over months to years to hypopigmented, atrophic, wrinkled scars (striae albae). The marks are perpendicular to the direction of skin tension. They fade with time. In pregnancy, they occur on the abdomen, breasts, and thighs. In adolescents, they are common on thighs, buttocks, breasts (females) and back (males).

Striae rubrae are sometimes pruritic. Otherwise, striae are asymptomatic. Treatment is sought because of their unsightly appearance.

Evaluation

Authors have used various methods of assessing the type and severity of striae when discussing the efficacy of treatments. These are not standardized or validated. Dermoscopy shows increased melanization in striae rubrae and reduced melanization in striae albae. [13] A biopsy is not necessary or useful.

Treatment / Management

The aim of treatment is to reduce redness, swelling and irritation in striae rubrae, and to increase collagen and elastic fiber production, improve hydration, and reduce inflammation in striae albae.[14]

Topical management is commonly recommended to prevent and treat striae, with very little if any evidence of efficacy, according to several published comprehensive reviews. Clinical trials have been of low quality involving small numbers of subjects.

  • Many emollients and over-the-counter cosmeceuticals are marketed and used by pregnant women with the intention of preventing striae distensae or reducing their severity, resulting in considerable effort and expense, despite the considerable uncertainty whether any have benefit. [15]
  • Silicone gels are recommended for atrophic scars and may be used in striae distensae. Published results are difficult to interpret.[16]
  • Tretinoin cream has been reported to be possibly useful in striae rubrae when compared to placebo over a six-month period. It may result in irritation, redness, and peeling. It should not be applied during pregnancy due to its pregnancy category.[0][18]
  • Chemical peels using various acids have been used to treat striae. Efficacy is unknown. 

Physical treatments are also advocated but also have little evidence to support their use.

  • Massage is a component of topical therapy, and it is also used in scar management. [19]
  • Exposure to broadband ultraviolet radiation can cause repigmentation in striae alba but is reported to have temporary effect with loss of pigmentation within a few months.
  • Light and laser therapies have shown improvements in the appearance of striae, although it is uncertain which is best, and at what stage (rubrae, albae) they should be used. [19] Several laser types (e.g., pulse dye laser) target vascular chromophores in striae rubra and are reported to reduce redness and swelling.[20] Fractional lasers (e.g., Erbium-YAG) stimulate fibroblasts to produce collagen and elastin and can cause repigmentation in striae alba.[21]
  • Light and lasers cause short-term erythema and oedema. They should be avoided in darker skin types due to greater risk of adverse effects, particularly transient postinflammatory hyperpigmentation and persistent hypopigmentation. Non-ablative devices are safer than ablative lasers.
  • Radiofrequency energy devices emit high-frequency alternating electric current producing dermal heat. They are used to tighten the dermis, reduce wrinkles, and improve cellulite. Treatment promotes neocollagenesis, neoelastogenesis, and increased ground substances (proteoglycans) and should theoretically improve the appearance of striae. At least one published study has reported treatment was well tolerated, and the patients were satisfied with the results. A more recent advance has been the delivery of radiofrequency energy to a depth of 3.5 mm using a multiple needle delivery mode. Anecdotal reports are encouraging but proper studies are awaited. [0]
  • Other devices used have included microdermabrasion[23], galvanopuncture [24], needling [25], pulsed magnetic fields [0], and ultrasound devices.[26]

The effect of treatments is difficult to assess. For example, laser protocols use differing devices, fluence, pulse duration, spot size and treatment frequency and number.  The utility of combination strategies is unknown.[14]

Platelet-rich plasma injections are also under investigation.[27]

When using any of these modalities, it is important to have standardized pre-treatment and post-treatment photographs. Furthermore, it is important to take these photographs six and twelve months out after the course of treatments. Many published reports do not have standardized photographs, nor do they have long-term follow up. 

Enhancing Healthcare Team Outcomes

Over time, many striae improve. The best time to perform a treatment (with proper photographs as discussed) is once the striae have stabilized. Many creams for striae are promoted on the internet with little evidence of the efficacy. The public should be made aware that the efficacy is very limited Newer lasers and radiofrequency treatments hold promise as they do try to modify the vascularity and the collagen and perhaps the elastin. Again, there is no clear leader among the many lasers that are promoted. The needle radiofrequency seems to show promise as, in theory, the deeper deliver of the energy may allow "shrinkage" of the striae in all directions, thereby improving the overall appearance. (Level V).


  • Image 1612 Not availableImage 1612 Not available
    Contributed by DermNetNZ
Attributed To: Contributed by DermNetNZ

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Stretch Marks (Striae) - Questions

Take a quiz of the questions on this article.

Take Quiz
Which is true about striae distensae?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A female with naturally dark skin is concerned by hyperpigmented patches. She has been applying a cream she purchased overseas to try to lighten the marks, but it has not been effective. She reluctantly shows you her axillae, where there are hyperpigmented, pinkish, and hypopigmented, wide stretch marks. What does the cream contain?

(Move Mouse on Image to Enlarge)
  • Image 1616 Not availableImage 1616 Not available
    Contributed by DermNetNZ
Attributed To: Contributed by DermNetNZ



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 25-year-old woman presented with slowly increasing, hypo- and hyperpigmented, atrophic, linear marks on her upper arms. She admitted to having been applying a bleaching cream to the affected areas for the last 2 years, which she had purchased in a pharmacy in Africa. This cream contained which of the following ingredients?

(Move Mouse on Image to Enlarge)
  • Image 5788 Not availableImage 5788 Not available
    Contributed by DermNetNZ
Attributed To: Contributed by DermNetNZ



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A pregnant female has developed marked striae gravidarum. Which of the following measures has the best chance of minimizing the red marks?

(Move Mouse on Image to Enlarge)
  • Image 1612 Not availableImage 1612 Not available
    Contributed by DermNetNZ
Attributed To: Contributed by DermNetNZ



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 15-year-old male presents with his mother, who is concerned about stripes on his back, which she describes as whip marks. She says they have been present for several months. He denies having eaten any shiitake mushrooms or pruritis in the area of concern. What treatment may be effective for this condition?

(Move Mouse on Image to Enlarge)
  • Image 1614 Not availableImage 1614 Not available
    Contributed by DermNetNZ
Attributed To: Contributed by DermNetNZ



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Stretch Marks (Striae) - References

References

Farahnik B,Park K,Kroumpouzos G,Murase J, Striae gravidarum: Risk factors, prevention, and management. International journal of women's dermatology. 2017 Jun     [PubMed]
Lurie S,Matas Z,Fux A,Golan A,Sadan O, Association of serum relaxin with striae gravidarum in pregnant women. Archives of gynecology and obstetrics. 2011 Feb     [PubMed]
Wang F,Calderone K,Smith NR,Do TT,Helfrich YR,Johnson TR,Kang S,Voorhees JJ,Fisher GJ, Marked disruption and aberrant regulation of elastic fibres in early striae gravidarum. The British journal of dermatology. 2015 Dec     [PubMed]
Neve S,Kirtschig G, Elastotic striae associated with striae distensae after application of very potent topical corticosteroids. Clinical and experimental dermatology. 2006 May     [PubMed]
Ledoux M,Beauchet A,Fermanian C,Boileau C,Jondeau G,Saiag P, A case-control study of cutaneous signs in adult patients with Marfan disease: diagnostic value of striae. Journal of the American Academy of Dermatology. 2011 Feb     [PubMed]
Strumia R, Skin signs in anorexia nervosa. Dermato-endocrinology. 2009 Sep     [PubMed]
Gupta M, Medroxyprogesterone acetate [Depo Provera] injections. Development of striae. The British journal of family planning. 2000 Apr     [PubMed]
Sheu HM,Yu HS,Chang CH, Mast cell degranulation and elastolysis in the early stage of striae distensae. Journal of cutaneous pathology. 1991 Dec     [PubMed]
Zheng P,Lavker RM,Kligman AM, Anatomy of striae. The British journal of dermatology. 1985 Feb     [PubMed]
Hermanns JF,Piérard GE, High-resolution epiluminescence colorimetry of striae distensae. Journal of the European Academy of Dermatology and Venereology : JEADV. 2006 Mar     [PubMed]
Forbat E,Al-Niaimi F, Treatment of striae distensae: An evidence-based approach. Journal of cosmetic and laser therapy : official publication of the European Society for Laser Dermatology. 2018 Feb 16     [PubMed]
Rawlings AV,Bielfeldt S,Lombard KJ, A review of the effects of moisturizers on the appearance of scars and striae. International journal of cosmetic science. 2012 Dec     [PubMed]
Ud-Din S,McAnelly SL,Bowring A,Whiteside S,Morris J,Chaudhry I,Bayat A, A double-blind controlled clinical trial assessing the effect of topical gels on striae distensae (stretch marks): a non-invasive imaging, morphological and immunohistochemical study. Archives of dermatological research. 2013 Sep     [PubMed]
Korgavkar K,Wang F, Stretch marks during pregnancy: a review of topical prevention. The British journal of dermatology. 2015 Mar     [PubMed]
Timur Taşhan S,Kafkasli A, The effect of bitter almond oil and massaging on striae gravidarum in primiparaous women. Journal of clinical nursing. 2012 Jun     [PubMed]
Elsaie ML,Hussein MS,Tawfik AA,Emam HM,Badawi MA,Fawzy MM,Shokeir HA, Comparison of the effectiveness of two fluences using long-pulsed Nd:YAG laser in the treatment of striae distensae. Histological and morphometric evaluation. Lasers in medical science. 2016 Dec     [PubMed]
Zaleski-Larsen LA,Jones IT,Guiha I,Wu DC,Goldman MP, A Comparison Study of the Nonablative Fractional 1565-nm Er: glass and the Picosecond Fractional 1064/532-nm Nd: YAG Lasers in the Treatment of Striae Alba: A Split Body Double-Blinded Trial. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2018 Oct     [PubMed]
Hersant B,Niddam J,Meningaud JP, Comparison between the efficacy and safety of platelet-rich plasma vs microdermabrasion in the treatment of striae distensae: clinical and histopathological study. Journal of cosmetic dermatology. 2016 Dec     [PubMed]
Bitencourt S,Lunardelli A,Amaral RH,Dias HB,Boschi ES,de Oliveira JR, Safety and patient subjective efficacy of using galvanopuncture for the treatment of striae distensae. Journal of cosmetic dermatology. 2016 Dec     [PubMed]
Aust M,Walezko N, [Acne scars and striae distensae: Effective treatment with medical skin needling]. Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete. 2015 Oct     [PubMed]
Kravvas G,Veitch D,Al-Niaimi F, The use of energy devices in the treatment of striae: a systematic literature review. The Journal of dermatological treatment. 2018 Sep 7     [PubMed]
Gamil HD,Ibrahim SA,Ebrahim HM,Albalat W, Platelet-Rich Plasma Versus Tretinoin in Treatment of Striae Distensae: A Comparative Study. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2018 May     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Maternal and Fetal. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Maternal and Fetal, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Maternal and Fetal, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Maternal and Fetal. When it is time for the Surgery-Maternal and Fetal board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Maternal and Fetal.