Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 18/03/2015
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Jason J. Emer and Hooman Khorasani
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Striae distensae are extremely common lesions that do not cause medical problems. Early striae (striae rubra) are linear red-to-violaceous patches or plaques that may be pruritic. Gradually, they become white, atrophic, linear depressed patches along lines of skin tension. They are considered to be linear dermal scars with epidermal atrophy as evidenced a finely wrinkled appearance and telangiectasia. Common locations include the breasts and abdomen of pregnant women, and the shoulders of body builders. Striae are common in teenagers undergoing their growth spurts and in overweight individuals. Extensive striae that are deeper and wider, and include facial skin, are seen with long-term systemic corticosteroid use. Striae are likely the result of a combination of factors including genetics, mechanical stress (e.g., growth spurt, body-building, pregnancy), and hormones (e.g., cortisol, estrogen). Although striae will generally fade and become inconspicuous, patients frequently request cosmetic treatments.
The goal of treatment is a gradual, incremental improvement. In general, the ‘older’ the lesion (striae alba) the less dramatic and more slowly the treatment response will be. The best results are achieved by combining multiple treatment modalities early in the course of evolution. Currently, no ‘gold standard’ treatment modality has been determined.
Several studies have shown that topical tretinoin improves the appearance of striae. Based on these reports, striae rubra respond better to this therapy. Although not formally investigated, it is expected that other topical retinoids (e.g., tazarotene, adapalene) may also provide some improvement.
Non-ablative lasers produce improvement by stimulating an increase in dermal collagen and elastin. The pulsed dye laser has been most studied. Recent studies suggest that improvement is more common in early striae that are pink-to-red in color. Ablative lasers may be more useful than the non-ablative counterparts, but have more significant downtime and an increased risk of complications. Radiofrequency devices may work by a similar mechanism of dermal heating. In the near future, sublative fractional bipolar radiofrequency devices, which work by a novel mechanism of dermal heating without epidermal disruption, may be of benefit. The excimer laser, intense pulsed light, and glycolic acid products appear to be the most promising treatments for mature striae.
Thorough history and physical examination
Skin biopsy (not generally necessary)
Serum adrenocorticotropin levels, 24-hour urine free cortisol level, plasma cortisol levels (if no history of growth spurt, body-building or pregnancy)
The diagnosis and cause of striae are usually straightforward to elucidate. When the lesions are particularly severe and the cause is unknown, laboratory testing to exclude Cushing syndrome is advised. In Cushing syndrome, striae are characterized by their excessive size, depth, and striking red-to-purple color. Occasionally, striae may be confused with linear focal elastosis, which are striae-like, asymptomatic, slightly palpable, yellow bands commonly found on the lower back of older adults. Histological evaluation, with specific attention given to the elastic fiber content, will clearly differentiate these two entities.
It is well known that striae tend to become less conspicuous with time. Thus, reassurance may be all that is required for the patient who is not overly concerned about his or her striae.
Ammar NM, Roa B, Schwartz RA, Janniger CK. Cutis 2000; 65: 69–70.
Nigam PK. Int J Dermatol 1989; 28: 426–7.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Observation
Fractional photothermolysis 10 600 nm laser
Fractional photothermolysis 10 600 nm laser/succinylated atelocollagen
Fractional photothermolysis 1 550 nm laser
Pulsed dye laser (585 nm)
Topical tretinoin
