Striae distensae | CCID

Introduction

Striae distensae (SD) (stretch marks/striae gravidarum) is a typical dermal lesion that may happen throughout being pregnant, adolescence, and weight problems in addition to illness (eg Cushing’s syndrome/persistent steroid use). Within the out there literature, the prevalence of SD has been described as various from 11% to 88%, with the overwhelming majority of SD sufferers being pregnant ladies and adolescents and pregnancy-related SD, also referred to as SG (striae gravidarum). Analysis on the therapy of SD has been a scorching matter as a consequence of its excessive prevalence and the psychosocial problems it causes, which severely impacts sufferers’ high quality of life. SD is split into striae rubrae (SR) and striae albae (SA). SR seems as pink/purple, flat, or generally barely convex striae within the early stage and develop into white striae known as SA within the late stage as a consequence of melanin discount and atrophy. SD is commonly situated within the stomach, breasts, buttocks, and thighs.^1–3 Research have proven that maternal underage or weight acquire throughout being pregnant is related to SG formation. In distinction, fetal start weight, gestational age at supply, and household historical past of SG are related to reasonable and extreme SG.⁴

The pathogenesis of SD is unclear, however the prevailing view is that it’s associated to adjustments within the extracellular matrix (ECM) parts, together with fibrillin, elastin, and collagens. These constructions present pores and skin resistance to rigidity and elasticity. In comparison with regular pores and skin, sufferers with SD had elevated glycosaminoglycan content material and a major lower in vertical fibrillin fibres underneath the dermal-epidermal junction (DEJ) and elastic fiber dermis. The orientation of elastin and fibrillin fibres within the deep dermis was realigned.⁵ Within the early phases of SD, the elastic fiber community is markedly disrupted, and the newly synthesized tropoelastin-rich fibrils are skinny and disorganized and don’t work like commonplace elastic fibers to provide the pores and skin laxity of SD.⁶ Along with the numerous separation of collagen bundles throughout this era, the newly disorganized collagen fibrils can not restore the collagen bundles as a consequence of intense pores and skin stretching, which collectively results in atrophy of SD.⁷

There are numerous therapy modalities for SD, however there’s nonetheless no “gold commonplace” for SD therapy. Single therapy modalities for SD embrace topical therapy, lasers, gentle units, and others, with lasers and light-weight units being more practical and extensively used than topical therapy. Lately, extra mixture therapies have been proposed and tried. Usually, they’re extra clinically efficient than single therapies, nevertheless it depends upon the kind of therapies mixed.² Among the many therapy modalities which were explored thus far, the therapeutic targets broadly embrace growing collagen manufacturing, lowering vascularity, growing pigmentation, and others.³

Topical Therapy

Tretinoin

Tretinoin is a acknowledged therapy for repairing pores and skin injury related to photoaged pores and skin and histologic adjustments have been proven to be related to reversal of photodamage, comparable to elevated collagen manufacturing, fibroblast exercise and angiogenesis. Due to this fact, some researchers tried to make use of tretinoin to deal with pores and skin injury attributable to extreme stretching.⁸ A 0.1% retinoic acid has a superb medical end result for pregnancy-related SD, and many of the present literature confirms its use within the therapy of SR.^2,3 In a multicenter potential examine, 20 sufferers handled with 1% retinoic acid for 12 weeks confirmed a 20% discount in SG size in comparison with the management group. Erythema, scarring, pruritus, and burning sensation have been anticipated antagonistic results, most of which appeared early within the therapy interval and steadily resolved with emollients.⁹ In the meantime, within the Hexsel et¹⁰ examine, the medical effectiveness of 0.05% retinoic acid in comparison with superficial dermabrasion for SR was evaluated. The width and size of the handled SD have been measured, which have been the principle outcomes. A 5-point scale was used to judge the International Aesthetic Enchancment Scale (GAIS: worse, no change, improved, a lot improved, very a lot improved) and affected person satisfaction (very unhappy, unhappy, neither glad nor unhappy, glad, very glad) within the therapy space. The width and size of SD have been considerably decreased in each teams after therapy. All of the sufferers have been glad or detached and nobody was dissatisfied. Each confirmed important enhancements in medical efficiency, affected person satisfaction, and aesthetic scores in SR. Different research demonstrated no important enchancment in SD after seven months of 0.025% retinoic acid therapy.¹¹ Low ranges of tretinoin stands out as the major trigger.

Glycolic Acid (GA)

Glycolic acid is an efficient peeling agent, and topical utility of 25% AHAs (glycolic, lactic, and citric acid) can enhance the thickness of the dermis and papillary dermis, enhance acid mucopolysaccharide, enhance the standard of elastic fibers, and enhance collagen density. The mixture of GA and the tretinoin talked about above is efficient in lowering photodamaged pores and skin, as is AHAs, and the mix is a secure and efficient therapy for pimples vulgaris. It isn’t arduous to see GA being primarily utilized in mixture with different remedies. For instance, in a examine by Ash et al⁸ 10 SA samples of various Fitzpatrick pores and skin sorts (I–IV) have been chosen. The target blind technique is completed by visible grading technique and histopathologic evaluation was carried out. Each remedies elevated the epidermal thickness in comparison with untreated striae distensae. The applying of 20% GA together with 0.05% retinoic acid or 10% L-ascorbic acid was secure and efficient in enhancing the medical efficiency of SA. The unwanted side effects have been lower than gentle irritation. Glycolic acid can co-regulate collagen synthesis by means of cytokines launched by fibroblasts and keratin-forming cells. In a double-blind managed examine, the therapy of 40 SD sufferers with 70% GA for six months was efficient in lowering the striae width and hemoglobin content material of SR and considerably lowering SA striae width and growing melanin deposition, however not wholly repairing SD.¹²

Lasers and Gentle Gadgets

Ablative Lasers

Fractional CO₂ Laser (FrCO₂)

The Fractional Ablative CO₂ laser is essentially the most generally used laser therapy for SD and has passable efficacy in selling the regeneration and reworking of collagen and elastin fibers.² Within the examine by Crocco et al,¹³ 13 SG sufferers have been handled with a ten,600-nm Fractional CO₂ laser, and every affected person skilled 4 periods of accelerating pulse vitality ranges (80, 90, 100 and 110 m J/MTZ), respectively. Most striae widths and pores and skin tissue biopsies have been measured earlier than and after therapy. Biopsies of untreated regular pores and skin have been additionally obtained, and superficial and deep pores and skin tissue samples for evaluation of collagen fibers and up to date, intermediate, and mature elastic fiber adjustments. The width of the most important striae was considerably decreased after therapy, with important thickening of the epidermal cell layer and a major enhance in collagen fibers, which weren’t considerably totally different from regular untreated pores and skin. Nonetheless, no important enhance within the variety of elastic fibers was seen in all durations, which the researchers speculate could also be associated to the extra thermal stability of elastic and collagen fibers. It was reported that clear boundary traces and parallel collagen fibers appeared within the distorted dermo-epidermal junction space as potential markers of SD enchancment when the handled pores and skin was noticed by reflectance confocal microscopy. Of concern is that the upper the laser vitality, the larger the chance of post-inflammatory hyperpigmentation, and in some sufferers, PIH can last as long as a yr.¹⁴ Research have additionally proven comparable efficacy of FrCO₂ laser and micro-needling for SR.¹⁵

Fractional Er:YAG Laser

Fractional Er:YAG laser has comparable therapy results to the Fractional Ablative CO₂ laser described above, however the 2940 nm Er:YAG causes much less thermal injury to the encompassing tissues and thus permits for sooner wound therapeutic inflicting milder unwanted side effects comparable to erythema, edema, and PIH. PIH is harder to just accept for Fitzpatrick pores and skin sort IV–V folks so it may be used as favorable different therapy for darker pores and skin folks.¹⁶ It was reported that the researchers utilized quick pulse (SP) mode plus clean (SM) mode to deal with one facet of SD and the opposite facet with two quick pulses (SP) modes for 2 months. All SD volumes have been considerably decreased, and all sufferers confirmed greater than 25% enchancment. There was no important distinction between the 2 modalities relating to therapy impact. Nonetheless, on the 6-month follow-up, the incidence of PIH within the SM&SP mannequin was solely 12.5% in contrast with 23.5% in SP&SP. Researchers imagine that is associated to the SM mode slowly penetrating warmth from the pores and skin floor into the deeper tissues, leading to minor thermal injury. Due to this fact, to stop and cut back PIH in dark-skinned folks, it’s mandatory to use SM mode and topical preparations of the affected space pre- and post-treatment.¹⁷ Apparently, two years later, Meningaud et al¹⁸ explored another therapy modality to scale back PIH and shorten restoration time. Making use of a 2940 nm Er:YAG laser with an SMA module to separate the laser beam into a number of micro spots scanning patterns, which solely penetrate the dermis by 50 mm, whereas additionally inducing acoustic waves technology to advertise tissue regeneration. A 85% of sufferers reported nice enchancment, with important enhancements in pores and skin thickness, elasticity, and high quality within the affected areas by instrumental evaluation. Solely 15% reported common or slight enchancment. These sufferers had late-stage and mature SD, which the researchers imagine might be improved by growing the variety of therapy periods or lowering the interval between every therapy, however this could additionally require a bigger RCT trial to display. The examine means that the 2940 nm Er:YAG laser requires at the least six remedies to be efficient and that no unwanted side effects occurred within the 20 sufferers with long-term follow-up whereas restoration time was solely 5 days. As well as, one other examine evaluated the efficacy of laser therapy of SA with a 2940 nm Er:YAG laser for six periods, supplemented with bovine primary fibroblast development issue (rb-bFGF) for one week light-emitting diode-red gentle (LED-RL) each seven days between laser remedies. At 6-month follow-up, 27 of 30 sufferers reported greater than 50% enchancment. On the identical time, biopsies recommended thickening of each dermis and dermis and a rise within the density of each elastic and collagen fibers.¹⁶

Non-Ablative Lasers

Er:Glass Laser

Provided that histologically SD and scar therapeutic are very comparable, the 1540-nm Er:glass laser can allow dermal reworking to deal with atrophic scarring, which has just lately been tried in research to deal with SD. The researchers utilized therapy 2 to 4 instances, and after a one-month follow-up biopsy comparability, the dermis and dermis have been thickened, and collagen fibers and elastic fibers have been elevated. After three months, picture comparability revealed a 50–75% enchancment in all SD. After six months and even longer follow-up, sufferers had greater than 50% enchancment by visible evaluation, and none had a recurrence. As well as, the examine means that the optimum therapy parameters for the laser are 30 to 50 m J/µb, and it’s hypothesized that the stamping mode vitality sample is extra appropriate for SD therapy, making certain the effectiveness and constant distribution of microbeams into the pores and skin. Additionally, this examine chosen 51 sufferers (II–IV), together with SR and SA, through which 14% striae of greater than 20 years and the farthest years have been 40 years. Due to the expertise with the therapy of the striae ranging in maturation age from 1 to 40 years, the researchers suggest a unique view from the earlier therapy of SD. They concluded that the prevalence of the therapy impact lies extra within the size, width, and density of Striae in comparison with the maturity of SD.¹⁹ In a potential examine, the Fractional 1565-nm Er:glass with picosecond 1064 nm or 532nm Nd:YAG laser was evaluated to be equally efficient in treating SA.²⁰

Picosecond Lasers

Within the examine by Fusano et al²¹ after 27 Caucasian ladies with SA have been handled with the 1064 nm picosecond laser over 4 months, clinicians noticed medical enchancment in 81.4% of sufferers and 66.6% of sufferers perceived medical enchancment and passable outcomes. In the meantime, on the 6-month follow-up, the 3D evaluation confirmed a major enchancment within the general texture and depth of the striae. Nonetheless, no important discount in width and collagen reworking and dermal papillae have been noticed at Reflectance Confocal Microscopy (RCM), all of which point out that 1064 nm picosecond laser therapy is an efficient therapy possibility for SA however not a whole treatment. After one yr, the identical conclusions have been reached in one other examine evaluating the efficacy of 1064-nm picosecond laser therapy in 20 sufferers with dark-skinned (IV–V) SA. At 6-month follow-up, greater than 90% of sufferers reported reasonable to important enchancment, sustained enchancment in pores and skin texture, extra evenness of striae shade, and unwanted side effects of solely gentle erythema, edema, crusting, and PIH, with a ten% incidence of PIH.²²

Pulsed Dye Laser (PDL)

PDL will increase collagen fiber manufacturing and reduces the diploma of erythema in SR, which considerably improves SR.^23,24 Primarily based on the excessive affinity of hemoglobin for 585 nm PDL throughout therapy, all can successfully cut back the diploma of erythema of SR.²³ Additionally, as a result of melanin as a chromogenic group competes with hemoglobin for the sunshine vitality from the 585 nm PDL, dark-skinned persons are extremely inclined to PIH, so even low-energy lasers are usually not really helpful to be used in dark-skinned (IV–V) folks. The examine by GLORIA et al²⁴ demonstrated that 585 nm PDL was efficient in enhancing SR however had no important medical efficacy in SA, regardless that a rise in collagen fibers was detected in SA after therapy. This conclusion was equally supported in one other examine, confirming that IPL and PDL are equally efficient for SR.

Nd:YAG Laser

In a examine carried out by Elsaie et al²⁵ evaluating the efficacy of two energies (75 and 100 J/cm²) of long-pulsed Nd:YAG laser within the therapy of SD, it was confirmed that 100 J/cm² improved the looks of SA considerably, whereas 75 J/cm² was more practical for SR, with a major enhance in collagen fibers and elastic fibers in post-treatment pattern, and passable adjustments have been noticed from each medical and histological analysis. The pores and skin shade of the 45 sufferers on this examine pattern included III–V, the place the dark-skinned inhabitants didn’t present important PIH.

Lights

Intense Pulsed Gentle (IPL)

In a potential examine evaluating the efficacy of IPL for SA at wavelengths between 515 nm and 1200 nm, all 15 sufferers reported passable outcomes, with the common variety of SD per affected person lowering from 7.8 to six.26. The common size of SD decreased from 25 cm to fifteen.93 cm. There was a rise in each epidermal and dermal thickness underneath the microscope, confirming the effectiveness of IPL for the therapy of SA.²⁶

Others

Radiofrequency (RF)

A potential randomized managed examine carried out by Harmelin et al²⁷ evaluated the impact of Fractionated Bipolar Radiofrequency versus Bipolar Radiofrequency Potentiated by Infrared Gentle for the therapy of SD. The stomach was divided into 4 quadrants representing the 4 teams: the clean group, the 2 separate RF teams, and the mixed therapy group. On the 6-month follow-up of the mixed therapy group, 3D pictures confirmed a 21.6% lower in imply streak depth and a 1.73% enhance within the management group. The distribution of collagen fibers was extra uniform than in pre-treatment, and the distribution of elastic fibers was decreased. Each the doctor and the affected person reported important enchancment in SD however not within the width of the striae. The efficacy of mixture remedy is superior to monotherapy in all facets and is an efficient therapy modality for SA and SR. Negative effects have been primarily related to Fractionated Bipolar Radiofrequency, and the presence of PIH in two sufferers suggests warning in dark-skinned folks. Apparently, in a examine by Manuskiatti et al²⁸ it was famous that TriPollar RF is a superb different therapy even for dark-skinned folks. Enchancment of greater than 50% was perceived by 11.8% of sufferers after only one week of therapy, and protracted enchancment was discovered at a follow-up form of 6 weeks later. The medical end result of 1 affected person with SR was higher than all different SA sufferers, with 65% of sufferers reporting passable therapy outcomes. Much more satisfying for sufferers is that TriPollar RF unwanted side effects are solely temporary and gentle erythema and edema whereas being primarily painless. From the outcomes of the 2 analysis experiments talked about above, the authors concluded that the therapy of SD requires creating an individualized therapy plan. Deciding on therapy parameters and frequency and intervals must be thought of completely in line with varied facets such because the affected person’s pores and skin shade, striae depth, medical response, and tolerance degree.

Micro-Needling

In contrast to laser remedies, micro-needling doesn’t trigger thermal damage to the pores and skin, so it reduces the chance of post-inflammatory hyperpigmentation, particularly for darker pores and skin phototypes. The benefits of fewer unwanted side effects, shorter restoration time, and decrease value have made it a scorching spot for SD therapy within the final two years. The precept of motion is much like that of laser in that it promotes new collagen synthesis and dermal reworking by means of dermal injury. In a current examine of 25 SD sufferers (I–V) handled with 1–3 consecutive Micro-needling periods, all striae improved by greater than 50%, and 28% of SD sufferers demonstrated greater than 75% enchancment. There was no important distinction in efficacy between sufferers with totally different pores and skin sorts and no distinction between thicker and thinner pores and skin areas.²⁹ West et al³⁰ utilized micro-needling to deal with SR. Biopsies confirmed many common collagen fiber bundles and dermal fibroblast proliferation however an insignificant enhance in elastic fibers. Aside from one case of Fitzpatrick sort VI pores and skin with PIH that resolved with topical therapy comparable to retinoic acid, no distant PIH appeared. In one other examine, micro-needling was proven to be as efficient as 1340 nm Nd: YAP non-ablative fractional laser within the therapy of SA, and it was additionally noticed that ache was extra pronounced within the micro-needling group, so it was recommended that when the penetration depth was larger than 3 mm, native anesthetics have been wanted to pre-treatment.³¹ Research have additionally proven {that a} mixture of micro-needling with PRP is more practical than micro-needling alone.³²

Platelet-Wealthy Plasma (PRP)

PRP is a concentrated platelet centrifuged and sunk right into a small quantity of plasma. PRP induces extracellular matrix reworking, collagen fiber, and elastic fiber formation.

Research have proven that native PRP injections are more practical than 0.05% retinoic acid for SA, particularly striae alba. Of the 30 SD sufferers, 86.6% of the PRP group reported enchancment, and affected person satisfaction was 89.9%, in contrast with 60% within the retinoic acid group in each areas. On the identical time, PRP additionally had the benefits of easy accessibility and no threat of hyperpigmentation or an infection.³³ It has additionally been proven that PRP and carboxytherapy are primarily equal within the therapy of SA.³⁴ This yr, Ebrahim et al³⁵ researchers tried the prevalence of PRP mixed with subcision or peeling/medium-depth peeling (GA 70% + TCA 35%) in comparison with PRP alone. After medical enchancment, sufferers’ satisfaction and Dermatology Life High quality Index (DLQI), and pores and skin biopsy assessments, it was confirmed that each mixed remedies have been superior to PRP alone. On the identical time, subcutaneous separation was superior within the therapy of SA and safer in dark-skinned populations.

Microdermabrasion (MDA)

Microdermabrasion removes aged pores and skin cells by means of mechanical injury and stimulates new cell manufacturing, collagen fiber, and elastic fiber synthesis. In an RCT involving 48 SA, it was demonstrated that each Galvano-puncture and MDA successfully decreased the size and width of SA, with thermography displaying extra important enchancment with Galvano-puncture and no statistically important distinction in ache.³⁶ In one other single-center medical trial, Hexsel et al¹⁰ evaluated the efficacy of Superficial Dermabrasion versus 0.05% retinoic acid for the therapy of 32 SR. Confirmed by evaluating the width and size of the striae, International Aesthetic Enchancment Scale scores, affected person satisfaction, and histological evaluation, each remedies have been considerably efficient and didn’t differ. As well as, histological evaluation confirmed a discount in elastolysis, collagen fragmentation, epidermal atrophy, and an enchancment in dermis and dermis, confirming the medical presentation. Each exhibited pruritus, erythema, and scaling. Nonetheless, the incidence was larger within the retinoic acid group, which led to higher affected person compliance and security in superficial dermabrasion, which the researchers concluded might be used for early and localized SR.

Carboxytherapy

Carboxytherapy, which means cutaneous and subcutaneous injection of carbon dioxide fuel, has been common in dermal rejuvenation remedies since 1995. Water molecules react with carbon dioxide to provide molecular carbonic acid, which cut back the pH of tissue. In keeping with the Bohr impact, this causes hemoglobin to launch oxygen and microcirculatory vasodilation, whereas growing peripheral blood movement (Bohr impact: A lower in pH may cause a lower within the affinity of hemoglobin and oxygen). Tissue stretching throughout carbon dioxide injection induces subclinical irritation that prompts macrophages, fibroblasts and endothelial cells. This stimulates neovascularization and extracellular matrix reworking for pores and skin restore and tissue regeneration.³⁷ Research have proven carboxytherapy successfully improves the pores and skin elasticity of SD, lowering the width and size of striae. On the identical time, the colour of SD turns into extra just like the pure pores and skin, with hematoma being essentially the most important facet impact.³⁸ Lately, Elmorsy et al³⁷ demonstrated no important distinction in efficacy between carboxytherapy and FrCO₂. As much as 80% of SD sufferers had important medical enchancment with carboxytherapy. SR was more practical than SA. The imply striae size decreased from 13.1 cm to 9.3 cm after just one month of therapy, and no affected person within the carboxytherapy group had extra extreme striae than FrCO₂. The vast majority of the pattern inhabitants on this examine was Fitzpatrick pores and skin sort IV. No sufferers skilled PIH with carboxytherapy. Solely non permanent erythema and bruising on the injection web site. One other examine recommended that the medical enchancment of the carboxytherapy was akin to the PRP. Nonetheless, sufferers’ satisfaction was larger with carboxytherapy. As a result of PRP was extra more likely to have ache and ecchymosis, carboxytherapy was efficient for any a part of the physique and each forms of SD.³⁹ A few of the medical trials of single therapy modalities have been tabulated in Desk 1.

Desk 1 Medical Trials of Single Therapy Modalities

Mixture Therapies

RF Plus Others

Microneedling and radiofrequency (MRF) have been efficiently utilized to deal with atrophic scarring and facial wrinkles in recent times. Many researchers have tried to make use of it to deal with SD, given the similarity between them, the histological traits of SD, and atrophic scarring. Within the examine by Al-Muriesh et al⁴⁰ non-insulated MRF with FrCO₂ indicated an enchancment and no statistical distinction within the therapy of SD as assessed by the International Aesthetic Enchancment Scale, dermoscopy, and VISIA imager (3D photos). The VISIA system makes use of digital shadow overlaps to offer reproducible concentrating on to precisely observe adjustments earlier than and after therapy on the identical place, generate corresponding common and rendered 3D photos. Common photos embrace pores and skin tone and grayscale {photograph} to measure the depth and vary of pores and skin shade adjustments. Pink and yellow shade in rendered 3D photos characterize the elevation of the pores and skin, on this case SD lesions. These 3D photos could make up for the deficiencies visible distinction in 2-dimensional photos. Each teams after therapy, rendered 3D photos confirmed a lower in pink and yellow shade, whereas grayscale and pores and skin tone shade confirmed flatten of SD. Dermoscopy revealed a 5–32% discount in striae width within the MRF group and a 6–31% discount within the FrCO2 group. The ache index was considerably larger within the MRF group however was tolerated by each sufferers, and though PIH occurred in each teams, it was extra more likely to happen within the FrCO₂ group. The above findings are typically per these of Sobhi et al.⁴¹ The one distinction is the absence of PIH within the MRF group within the latter examine, which the authors recommend is said to the selection of the therapy protocol and instrumentation in addition to pre- and post-treatment administration. In one other examine, they requested whether or not the mix of FrCO₂ and MRF for SD might enhance efficacy and cut back unwanted side effects, given the paradox that high-energy FrCO₂ is more practical for SD and has a larger threat of inflicting PIH. The outcomes confirmed a barely extra important enchancment with the mix therapy than the standard FrCO₂ therapy. The hyperpigmentation and erythema severity have been extra extreme than within the MRF group. On the identical time, the unwanted side effects are much like the FrCO₂ group. After a mixed therapy, the pores and skin ultrasound scanner confirmed a rise in common pores and skin thickness of 204.9 μm and a rise in dermal density of 8.8%, indicating that the dermal enchancment would final for a extra prolonged time.⁴² As well as, it has been proven that the efficacy of MRF and Er:YAG therapy for SA is comparable. Nonetheless, the dermal and epidermal thickening within the MRF group was extra important however not statistically totally different within the optical coherence tomography instrument.⁴³ It’s noteworthy that no PIH was reported within the MRF group within the latter two research, in line with Sobhi above. MRF is extra able to stimulating SA collagen fiber regeneration than NAFL however is extra painful.⁴⁴

Ablative Fractional radiofrequency mixed with Acoustic Stress Ultrasound transdermal supply of 0.05% retinoic acid cream can be an efficient therapy modality for SA. Combining the 2 units can enhance the penetration of retinoic acid and enhance the medical efficacy with an enchancment of as much as 76–100% with fewer unwanted side effects and just one case of PIH.⁴⁵ Sublative bipolar fractional radiofrequency mixed with 0.1% retinoic acid is a promising therapy modality for SG.⁴⁶

FrCO₂ Plus Others

A randomized, double-blind examine in contrast the efficacy of FrCO₂ mixed with recombinant human epidermal development issue (AFXL-rhEGF) and FrCO₂ mixed with aloe vera gel (AFXL-Aloe) within the therapy of SA. Human epidermal development issue and aloe vera gel are hydrophilic substances that may penetrate deeper into the pores and skin by means of the MTZ produced by FrCO₂ to attain higher efficacy. The outcomes confirmed a major enchancment in each subjective and goal assessments, which lasted for as much as 6 months. At 6-month follow-up, as much as 50% of sufferers reported important enchancment in affected person satisfaction with AFXL-rhEGF in contrast with solely 25% with AFXL-Aloe. On the identical time, each had higher efficacy within the SD of the buttocks than the thighs and stomach. With little distinction in efficacy, AFXL-Aloe is considerably extra economical. Notably, the 24 SA concerned on this examine have been all dark-skinned (III–IV) and had a excessive incidence of PIH of 95.8%, however hyperpigmentation improved on the 6-month follow-up.⁴⁷ Within the final two years, it has been proven that FrCO₂ mixed with PRP can be an efficient therapy for SD and is superior to FrCO₂ alone or PDL mixed with PRP.^48,49 A few of the medical trials of mixed therapy modalities have been tabulated in Desk 2.

Desk 2 Medical Trials of Mixed Therapy Modalities

Conclusion

Completely different pores and skin sorts have totally different reactions and unwanted side effects to the identical therapy. Regardless of some optimistic outcomes, the therapy of SD continues to be a fantastic problem, particularly for SA (end-stage of SD). Regardless of the constraints of the prevailing literature, mixed therapy is mostly more practical than single therapy. Tretinoin, FrCO₂ laser, Er:YAG laser, radiofrequency and microneedling have been clinically conscious of correct settings or concentrations in single therapy. FrCO₂ laser stays the preferred and efficient therapy, however the unwanted side effects of PIH deserve our consideration, particularly in dark-skinned folks. The mixture of radiofrequency and microneedling was the commonest therapy with good medical response and fewer unwanted side effects. Sooner or later, a common SD grading scale and a standardized manner of assessing post-treatment outcomes are anticipated to be established earlier than definitive conclusions might be obtained for extra correct comparative therapy. Combining remedy is presently a scorching matter in SD therapy and extra combos might be tried to enhance the efficacy, cut back unwanted side effects to attain a greater therapy impact and enhance affected person compliance. The examine’s design requires samples for various pores and skin sorts, optimum parameters, and protocols for varied therapy modalities, and follow-up of long-term outcomes are instructions that may be labored on sooner or later.

Consent for Publication

All authors have learn and permitted the ultimate manuscript for submission.

Disclosure

The authors report no conflicts of curiosity on this work.

References

1. Ud-Din S, McGeorge D, Bayat A. Topical administration of striae distensae (stretch marks): prevention and remedy of striae rubrae and albae. J Eur Acad Dermatol Venereol. 2016;30(2):211–222. doi:10.1111/jdv.13223

2. Seirafianpour F, Sodagar S, Mozafarpoor S, et al. Systematic overview of single and mixed remedies for various kinds of striae: a comparability of striae remedies. J Eur Acad Dermatol Venereol. 2021;35(11):2185–2198. doi:10.1111/jdv.17374

3. Hague A, Bayat A. Therapeutic targets within the administration of striae distensae: a scientific overview. J Am Acad Dermatol. 2017;77(3):559–568. doi:10.1016/j.jaad.2017.02.048

4. Osman H, Rubeiz N, Tamim H, et al. Danger elements for the event of striae gravidarum. Am J Obstet Gynecol. 2007;196(1):61–62. doi:10.1111/dsu.12460

5. Watson W, Parry P, Humphries H, et al. Fibrillin microfibrils are decreased in pores and skin exhibiting striae distensae. Br J Dermatol. 1998;138(6):931–937. doi:10.1046/j.1365-2133.1998.02257.x

6. Wang F, Calderone Okay, Smith NR, et al. Marked disruption and aberrant regulation of elastic fibres in early striae gravidarum. Br J Dermatol. 2015;173(6):1420–1430. doi:10.1111/bjd.14027

7. Wang F, Calderone Okay, Do TT, et al. Extreme disruption and disorganization of dermal collagen fibrils in early striae gravidarum. Br J Dermatol. 2018;178(3):749–760. doi:10.1111/bjd.15895

8. Ash Okay, Lord J, Zukowski M, et al. Comparability of topical remedy for striae alba (20% glycolic acid/0.05% tretinoin versus 20% glycolic acid/10% L-ascorbic acid). Dermatol Surg. 1998;24(8):849–856. doi:10.1111/j.1524-4725.1998.tb04262.x

9. Rangel O, Arias I, Garcia E, et al. Topical tretinoin 0.1% for pregnancy-related belly striae: an open-label, multicenter, potential examine. Adv Ther. 2001;18(4):181–186. doi:10.1007/BF02850112

10. Hexsel D, Soirefmann M, Porto MD, et al. Superficial dermabrasion versus topical tretinoin on early striae distensae: a randomized, pilot examine. Dermatol Surg. 2014;40(5):537–544.

11. Pribanich S, Simpson FG, Held B, et al. Low-dose tretinoin doesn’t enhance striae distensae: a double-blind, placebo-controlled examine. Cutis. 1994;54(2):121–124.

12. Mazzarello V, Farace F, Ena P, et al. A superficial texture evaluation of 70% glycolic acid topical remedy and striae distensae. Plast Reconstr Surg. 2012;129(3):589e–590e. doi:10.1097/PRS.0b013e3182419c40

13. Crocco EI, Muzy G, Schowe NM, et al. Fractional ablative carbon-dioxide laser therapy improves histologic and medical facets of striae gravidarum: a potential open label paired examine. J Am Acad Dermatol. 2018;79(2):363–364. doi:10.1016/j.jaad.2017.12.041

14. Guida S, Losi A, Greco M, et al. Reflectance confocal microscopy for striae distensae therapy monitoring after CO2 fractional laser. Dermatol Ther. 2020;33(6):e14318. doi:10.1111/dth.14318

15. Saki N, Rahimi F, Pezeshkian FS, et al. Comparability of the efficacy of microneedling versus CO2 fractional laser to deal with striae alba: a randomized medical trial. Dermatol Ther. 2022;35(1):e15212. doi:10.1111/dth.15212

16. Shen J, Lu XG, Jin JJ, et al. Mixture of a 2940 nm Er: yAGlaser with recombinant bovine primary fibroblast development issue (rb-bFGF) and light-emitting diode-red gentle (LED-RL) for the therapy of striae alba: a pilot examine. J Cosmet Dermatol. 2018;17(2):176–183. doi:10.1111/jocd.12376

17. Wanitphakdeedecha R, Meeprathom W, Manuskiatti W. A pilot examine of therapy of striae distensae with variable sq. pulse Erbium: YAG laser resurfacing. J Cosmet Dermatol. 2017;16(4):466–470. doi:10.1111/jocd.12391

18. Meningaud JP, SidAhmed-Mezi M, Billon R, et al. Medical advantage of utilizing a multifractional Er: yAGlaser mixed with a spatially modulated ablative (SMA) module for the therapy of striae distensae: a potential pilot examine in 20 sufferers. Lasers Surg Med. 2019;51(3):230–238. doi:10.1002/lsm.23042

19. de Angelis F, Kolesnikova L, Renato F, et al. Fractional nonablative 1540-nm laser therapy of striae distensae in Fitzpatrick pores and skin sorts II to IV: medical and histological outcomes. Aesthet Surg J. 2011;31(4):411–419. doi:10.1177/1090820X11402493

20. Zaleski-Larsen LA, Jones IT, Guiha I, et al. A comparability examine of the nonablative fractional 1565-nm Er: glass and the picosecond fractional 1064/532-nm Nd: YAG lasers within the therapy of striae alba: a break up physique double-blinded trial. Dermatol Surg. 2018;44(10):1311–1316. doi:10.1097/DSS.0000000000001555

21. Fusano M, Galimberti MG, Bencini M, et al. Picosecond laser therapy of striae distensae: in vivo analysis of outcomes by 3D evaluation, reflectance confocal microscopy, and affected person’s satisfaction. Lasers Surg Med. 2021;53(9):1180–1185. doi:10.1002/lsm.23401

22. Kaewkes A, Manuskiatti W, Cembrano KA, et al. Therapy of belly striae distensae in Fitzpatrick pores and skin sorts IV to V utilizing a 1064-nm picosecond laser with a fractionated microlens array. Lasers Surg Med. 2022;54(1):129–137. doi:10.1002/lsm.23471

23. Shokeir H, El BA, Sayed S, et al. Efficacy of pulsed dye laser versus intense pulsed gentle within the therapy of striae distensae. Dermatol Surg. 2014;40(6):632–640. doi:10.1111/dsu.0000000000000007

24. Jimenez GP, Flores F, Berman B, et al. Therapy of striae rubra and striae alba with the 585-nm pulsed-dye laser. Dermatol Surg. 2003;29(4):362–365. doi:10.1046/j.1524-4725.2003.29086.x

25. Elsaie ML, Hussein MS, Tawfik AA, et al. Comparability of the effectiveness of two fluences utilizing long-pulsed Nd: yAGlaser within the therapy of striae distensae. Histological and morphometric analysis. Lasers Med Sci. 2016;31(9):1845–1853. doi:10.1007/s10103-016-2060-2

26. Al-Dhalimi MA, Abo NA. A comparative examine of the effectiveness of intense pulsed gentle wavelengths (650 nm vs 590 nm) within the therapy of striae distensae. J Cosmet Laser Ther. 2013;15(3):120–125. doi:10.3109/14764172.2012.748200

27. Harmelin Y, Boineau D, Cardot-Leccia N, et al. Fractionated bipolar radiofrequency and bipolar radiofrequency potentiated by infrared gentle for treating striae: a potential randomized, comparative trial with goal analysis. Lasers Surg Med. 2016;48(3):245–253. doi:10.1002/lsm.22458

28. Manuskiatti W, Boonthaweeyuwat E, Varothai S. Therapy of striae distensae with a TriPollar radiofrequency system: a pilot examine. J Dermatolog Deal with. 2009;20(6):359–364. doi:10.3109/09546630903085278

29. Alster TS, Li MK. Microneedling therapy of striae distensae in gentle and darkish pores and skin with long-term follow-up. Dermatol Surg. 2020;46(4):459–464. doi:10.1097/DSS.0000000000002081

30. West L, He B, Vandergriff T, et al. Using microneedling to deal with striae distensae. Dermatol Surg. 2021;47(10):1407–1408. doi:10.1097/DSS.0000000000003151

31. Naspolini AP, Boza JC, Da SV, et al. Efficacy of microneedling versus fractional non-ablative laser to deal with striae alba: a randomized examine. Am J Clin Dermatol. 2019;20(2):277–287. doi:10.1007/s40257-018-0415-0

32. Abdel-Motaleb AA, Zedan H, Mostafa MM, et al. Mixed microneedling with topical utility of platelet-rich plasma versus microneedling alone within the therapy of stria distensae: clinicopathological evaluation. J Dermatolog Deal with. 2022;33(2):836–847. doi:10.1080/09546634.2020.1782323

33. Hodeib AA, Hassan G, Ragab M, et al. Medical and immunohistochemical comparative examine of the efficacy of carboxytherapy vs platelet-rich plasma in therapy of stretch marks. J Cosmet Dermatol. 2018;17(6):1008–1015. doi:10.1111/jocd.12481

34. Gamil HD, Ibrahim SA, Ebrahim HM, et al. Platelet-rich plasma versus tretinoin in therapy of striae distensae: a comparative examine. Dermatol Surg. 2018;44(5):697–704. doi:10.1097/DSS.0000000000001408

35. Ebrahim HM, Salem A, Salah T, et al. Subcision, chemical peels, and platelet-rich plasma: mixture approaches for the therapy of striae distensae. Dermatol Ther. 2022;35(2):e15245. doi:10.1111/dth.15245

36. Ferreira A, Guida A, Piccini AA, et al. Galvano-puncture and dermabrasion for striae distensae: a randomized managed trial. J Cosmet Laser Ther. 2019;21(1):39–43. doi:10.1080/14764172.2018.1444777

37. Elmorsy EH, Elgarem YF, Sallam ES, et al. Fractional carbon dioxide laser versus carboxytherapy in therapy of striae distensae. Lasers Surg Med. 2021;53(9):1173–1179. doi:10.1002/lsm.23418

38. Podgorna Okay, Kolodziejczak A, Rotsztejn H. Cutometric evaluation of elasticity of pores and skin with striae distensae following carboxytherapy. J Cosmet Dermatol. 2018;17(6):1170–1174. doi:10.1111/jocd.12465

39. Ahmed NA, Mostafa OM. Comparative examine between: carboxytherapy, platelet-rich plasma, and tripolar radiofrequency, their efficacy and tolerability in striae distensae. J Cosmet Dermatol. 2019;18(3):788–797. doi:10.1111/jocd.12685

40. Al-Muriesh M, Huang CZ, Ye Z, et al. Dermoscopy and VISIA imager evaluations of non-insulated microneedle radiofrequency versus fractional CO2 laser remedies of striae distensae. J Eur Acad Dermatol Venereol. 2020;34(8):1859–1866. doi:10.1111/jdv.16266

41. Sobhi RM, Mohamed IS, El SD, et al. Comparative examine between the efficacy of fractional micro-needle radiofrequency and fractional CO2 laser within the therapy of striae distensae. Lasers Med Sci. 2019;34(7):1295–1304. doi:10.1007/s10103-019-02792-7

42. Seong GH, Jin EM, Ryu TU, et al. Fractional radiofrequency microneedling mixed with fractional carbon dioxide laser therapy for striae distensae. Lasers Surg Med. 2021;53(2):219–226. doi:10.1002/lsm.23264

43. Nada HA, Sallam MA, Mohamed MN, et al. Optical coherence tomography-assisted analysis of fractional Er: yAGLaser versus fractional microneedling radiofrequency in treating striae alba. Lasers Surg Med. 2021;53(6):798–805. doi:10.1002/lsm.23349

44. Tang Z, Wen S, Liu T, et al. Comparative examine of therapy for striae alba stage striae gravidarum: 1565-nm non-ablative fractional laser versus fractional microneedle radiofrequency. Lasers Med Sci. 2021;36(9):1823–1830. doi:10.1007/s10103-020-03203-y

45. Issa MC, de Britto PKL, Chevrand NS, et al. Transepidermal retinoic acid supply utilizing ablative fractional radiofrequency related to acoustic stress ultrasound for stretch marks therapy. Lasers Surg Med. 2013;45(2):81–88. doi:10.1002/lsm.22105

46. Tian T, Luo Y, Wang H, et al. Efficacy and security of a sublative bipolar fractional radiofrequency system mixed with topical tretinoin in treating striae gravidarum: a randomized pilot examine. Dermatol Surg. 2019;45(10):1245–1252. doi:10.1097/DSS.0000000000001933

47. Disphanurat W, Kaewkes A, Suthiwartnarueput W. Comparability between topical recombinant human epidermal development issue and Aloe vera gel together with ablative fractional carbon dioxide laser as therapy for striae alba: a randomized double-blind trial. Lasers Surg Med. 2020;52(2):166–175. doi:10.1002/lsm.23052

48. Neinaa Y, Gheida SF, Mohamed D. Synergistic impact of platelet-rich plasma together with fractional carbon dioxide laser versus its mixture with pulsed dye laser in striae distensae: a comparative examine. Photodermatol Photoimmunol Photomed. 2021;37(3):214–223. doi:10.1111/phpp.12636

49. Preclaro I, Tianco E, Buenviaje-Beloso M. Efficacy of ablative fractional carbon dioxide laser mixed with autologous platelet-rich plasma versus ablative fractional carbon dioxide laser and placebo within the therapy of striae gravidarum: a randomized medical trial. J Cosmet Dermatol. 2022. doi:10.1111/jocd.14791