Are You Confident of the Diagnosis?

What you should be alert for in the history

Striae distensae are a common dermatologic complaint, most often affecting adolescents during puberty growth ’spurts’, or women in the last trimester of pregnancy. Striae can affect any area of the body, but in general spares the face. The appearance of striae is often distressing to patients.

Characteristic findings on physical examination

Physical exam reveals erythematous (early on) to white (later) linear lesions that follow cleavage lines. Striae are typically several centimeters in length and vary between a few millimeters to a few centimeters in width (Figure 1).

Figure 1.

Striae distensae on the abdomen of a young female

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Expected results of diagnostic studies

Histopathology shows a thin dermis with a reduction in collagen distribution in the upper dermis. Dermal elastin can also be reduced. Hair follicles and other appendages are absent.

Diagnosis confirmation

Differential diagnosis includes:

–Linear focal elastosis (elastotic striae) – palpable yellow striae rows on lower back; elderly men are most often affected.

–Striae from topical steroid abuse, such as in the treatment of psoriasis.

–Anetoderma – usually on the trunk; circumscribed areas of flaccid skin which can be elevated, depressed or macular; histopathology reveals focal or complete loss of elastic tissue in the dermis.

–Mid-dermal elastolysis – seen on the trunk, arms and side of the neck; diffuse areas of fine wrinkling and occasional perifollicular papules in middle-aged women; histopathology shows a selective loss of elastic fibers in the mid-dermis.

–Pseudoxanthoma elasticum – found on the lateral neck, axillae, groin and scars; exam reveals yellow coalescing skin papules and redundant folds in flexural sites; histopathology shows calcified and clumped elastic fibers in the mid-dermis.

–Cutis laxa – present on eyelids, cheeks, neck, shoulder girdle and abdomen; loose, sagging skin folds resulting in premature aging; histopathology reveals diminished and fragmented elastic fibers throughout the dermis.

Who is at Risk for Developing this Disease?

Certain patient populations are at an increased risk for developing striae distensae including obese patients, pregnant patients (especially in the last trimester), and pubescent males and females. Women are twice as likely as men to develop striae distensae. Patients on long term corticosteriod use or those with Cushing’s syndrome are also at an increased risk.

What is the Cause of the Disease?

Striae distensae results from cracks in the connective tissue forming atrophic dermal scars underneath an atrophic epidermal layer. The pathophysiology of striae distensae is not fully understood. Likely factors include genetics, hormones (especially corticosteriods) and mechanical stress to tissues.

Systemic Implications and Complications

The presence of striae distensae has no medical implications; however the cause of their appearance may need to be investigated. In patients presenting with striae distensae due to pubertal growth ’spurt’, increase in weight, pregnancy, and/or corticosteriod abuse, no further workup is required. In cases of suspected Cushing’s disease, referral to an endocrinologist is suggested.

Treatment Options

There is no cure for striae distensae, but topical and surgical treatments have had some impact in improving the appearance of this disorder.

Topical medical treatments

–Tretinoin 0.1% cream applied once each evening at bedtime; may start 3 times per week and increase as tolerated.

–AHAs-12% lactic acid or 15-20% glycolic acid twice a day as tolerated.

Both treatments may be of value in improving the appearance as well as the histology.

Surgical treatments

–585nm pulsed-dye laser and the Nd:Yag laser – most effective early on when striae are erythematous (striae rubra); performed at 4-6 week intervals, with the endpoint being a decrease in erythema.

–Short-pulsed carbon dioxide and erbium-substituted yttrium aluminium garnet (YAG) – used in patients with dark skin; one treatment.

–Fraxel (fractional photothermolysis, 1550nm) – may be effective to resurface the uneven skin edges of striae; may require 4-6 treatments; cost/benefit ratio must be entertained for each patient.

–Intense pulsed light (IPL, 515-1200nm) may be effective for the erythema and possibly resurfacing the uneven edges of the striae; cost/benefit ratio must be considered for each patient.

–Radiofrequency (RF) devices, chemical peels, and microdermabrasion have been reported to have modest improvement with striae.

–With all surgical treatments, care should be given to the darker skin patients as the risk of hyper or hypopigmentation can easily occur.

Optimal Therapeutic Approach for this Disease

Topically, the retinoids alone or in combination with AHAs have shown some improvement. However, the side effects of the retinoids on large surface areas can prohibit long term use due to redness, irritation and peeling.

Pulsed dye lasers, if employed when the striae are erythematous, are the best option to reduce the erythema and the remodeling of these lesions. When the lesions become older and are white, and if the patients are willing to tolerate the downtime and discomfort, then resurfacing procedures with lasers (CO2, erbium, fraxel, or fractionated lasers) can be considered, but patient expectations should be realistic. Radiofrequency with thermage has had photographic documentation of improvement, but cost considerations should be given. Reports of these treatments are anecdotal at best.

Prevention with moisturization has not been well documented. The use of retinoids would be prohibited in the pregnant or nursing population.

Patient Management

One approach is to speak with patients regarding the costs as well as the efficacy of these procedures. Since there is no guarantee that any procedure will afford complete correction of these lesions, patients should consider the cost and need for repeat treatment before deciding on the aforementioned treatments.

The risk of irritation with topical agents as well as lasers, especially in clothing covered areas, would impact treatment decisions as well.

Unusual Clinical Scenarios to Consider in Patient Management

One case report documented striae appearing all over the body in a 14 year old boy after the use of IV and oral corticosteroids.

What is the Evidence?

Elsaie, ML, Baumann, LS, Elsaaieff, L. “Striae distensae (stretch marks) and different modalities of therapy: an update”. Dermatol Surg. vol. 35. 2009. pp. 563-73. (Excellent review of topical and laser therapies for the treatment of striae distensae.)

Hernandez-Perez, E, Colombo-Charrier, E, Valencia-Ibiett, E. “Intense pulsed light in the treatment of striae distensae”. Dermatol Surg. vol. 228. 2002. pp. 1124-30. (Prospective study of 15 multiparous hispanic women with late stage striae distensae on the abdomen that received 5 total IPL sessions, administered once every 2 weeks. Gross and microscopical changes were documented, with all patients showing clinical and microscopic improvement in each parameter examined.)

Lee, SE, Kim, JH, Lee, SJ, Lee, JE, Kang, JM, Kim, YK. “Treatment of striae distensae using an ablative 10,600 nm carbon dioxide fractional laser: a retrospective review of 27 participants”. Dermatol Surg. vol. 36. 2010. pp. 1683-90. (27 Korean women with the presence of late stage striae distensae received one treatment with an ablative 10,600nm carbon dioxide fractional laser. Results showed an encouraging therapeutic effect as documented through clinical photographs and patient satisfaction scores.)

Maari, C, Powell, J. “Anetoderma and Other Atrophic Disorders of the Skin”. (Brief overview of the clinical findings, histopathology and treatment of striae distensae.)

McDaniel, DH. “Laser therapy of stretch marks”. Dermatol Clin. vol. 20. 2002. pp. 67-76. (Brief overview of striae distensae, with a focus on a literature review of laser therapies used in striae distensae, including nonablative laser therapies and infrared lasers, as well as adjunctive and nonlaser therapies (topical tretinoin and microdermabrasion.)

Rotsztejn, H, Juchniewicz, B, Nadolski, M, Wendorff, J, Kamer, B. “The unusually large striae distensae all over the body”. Adv Med Sci. vol. 55. 2010. pp. 343-5. (Case presentation of a 14 year old boy diagnosed with acute disseminated encephalomyelitis who went on to receive 5 Solu-Medrol IV injections, followed by 2mg of Dexamethason daily for 3.5 months, with a tapering of the medication over the next several months. In the first several weeks of treatment, the boy quickly developed large striae all over his body, with sparing of his face, hands and feet. ACTH and cortisol levels were normal.)