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Striae Distensae
Introduction
Striae distensae, commonly known as stretch marks, are a frequent dermatologic concern that can cause significant cosmetic and psychological distress. They typically appear on areas of the body prone to rapid stretching, including the abdomen, buttocks, thighs, breasts, back, axillae, and groin. They are classified according to appearance or epidemiology as follows:
- Striae atrophicans (thinned skin)
- Striae gravidarum (following pregnancy)
- Striae rubrae (red)
- Striae albae (white)
- Striae nigra (black)
- Striae caerulea (dark blue)
While striae are benign and asymptomatic, they are often a concern in dermatology and aesthetic medicine. For clinicians, distinguishing striae from other linear dermatoses (eg, linear morphea or anetoderma) is essential, as is understanding evidence-based prevention and treatment modalities—ranging from topical therapies and laser treatments to microneedling and emerging regenerative technologies.[1][2]
Etiology
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Etiology
Striae distensae are a form of dermal scarring associated with stretching of the dermis. They often result from a rapid weight change (gain and loss) or are associated with endogenous or exogenous corticosteroids. Proposed mechanisms relate to hormones, physical stretching, 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 as 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, and treatments, usually exogenous topical or systemic corticosteroids, or surgery.[5] Other associated diseases are Marfan syndrome [6], anorexia nervosa [7], various febrile illnesses, and chronic liver disease. Medications associated with striae include chemotherapy, prolonged antibiotic therapy, contraceptives [8], and neuroleptics. A positive family history is a risk factor for striae.[9]
Striae distensae are more common in females than males and may be more common in certain races. In 1 study, Black women were found to have a greater number of striae than White women of similar age, parity, weight gain, and family history.[10] Striae can appear more prominent in dark-skinned individuals. During pregnancy, striae are more common in younger women than in older women. Several studies have noted a greater prevalence with large abdominal circumference and significant weight gain (due to fetal size or polyhydramnios).[11]
Another study reported that striae were more prevalent in smokers than in nonsmokers. Medical comorbidities like urinary incontinence and pelvic floor dysfunction are associated with the presence of striae.[10][12]
Pathophysiology
The pathophysiology of striae distensae involves the disruption of dermal connective tissue, particularly collagen and elastin fibers, due to mechanical stretching and hormonal influences. Elastases released from mast cells and macrophage activity are believed to be involved.[13] Rapid skin expansion leads to structural damage in the dermis, while elevated levels of corticosteroids or genetic predisposition can impair fibroblast function and reduce collagen synthesis. Elastolysis of the mid-dermis is followed by a reorganization of collagen and fibrillin. This results in dermal atrophy and the characteristic linear, atrophic streaks. Inflammatory mediators are also believed to play a role, especially in the early stages, contributing to the erythematous appearance of striae rubrae before they evolve into hypopigmented striae albae.
Histopathology
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 is a 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] These striae appear similar to mature atrophic scars. Electron microscopy studies have also reported mast cell degranulation, macrophage activation, and elastolysis of the mid-dermis.[14]
History and Physical
History may explain the appearance of striae distensae by association with stretched skin, for example, in pregnancy, pubertal growth spurt, muscular exercise, or weight gain. Inquire about topical application of potent corticosteroids or prolonged systemic steroids during the recent or remote past. If striae are widespread and none of these explanations are relevant, take a complete medical history and conduct a thorough clinical examination.[15]
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 (see Image. Striae Gravidarum Rubrae). In adolescents, they are common on the 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.[16] These methods are not standardized or validated. Dermoscopy shows increased melanization in striae rubrae and reduced melanization in striae albae.[17] A biopsy is not necessary or useful for evaluation.
Treatment / Management
Treatment aims to reduce redness, swelling, and irritation in striae rubrae and in striae albae, to increase collagen and elastic fiber production, improve hydration, and reduce inflammation.[18]
According to several published comprehensive reviews, topical management is commonly recommended to prevent and treat striae, with very little, if any, evidence of efficacy. 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 to prevent striae distensae or reduce their severity, resulting in considerable effort and expense, despite the considerable uncertainty of any benefit.[19]
- Silicone gels are recommended for atrophic scars and may be used for striae distensae. Published results are challenging to interpret.[20]
- Tretinoin cream has been reported to be possibly useful in striae rubrae when compared to a placebo over a 6-month period. Tretinoin may result in irritation, redness, and peeling, and should not be applied during pregnancy due to its pregnancy risk category.[21][22]
- Chemical peels using various acids have been used to treat striae. Efficacy is unknown. (A1)
Physical treatments are also advocated, but little evidence supports their use.
- Massage can be a component of topical therapy; it is also used in scar management.[23]
- Exposure to broadband ultraviolet radiation can cause repigmentation in striae alba, but is reported to have a 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 therapy is best, and at what stage (rubrae, albae) they should be used.[23] Several laser types (eg, pulsed dye laser) target vascular chromophores in striae rubra and are reported to reduce redness and swelling.[24] Fractional lasers (eg, Erbium-YAG) stimulate fibroblasts to produce collagen and elastin and can cause repigmentation in striae alba.[25][26]
- Light and lasers cause short-term erythema and edema. They should be avoided in darker skin types due to a greater risk of adverse effects, particularly transient postinflammatory hyperpigmentation and persistent hypopigmentation. Nonablative devices are safer than ablative lasers.
- Radiofrequency energy devices emit high-frequency alternating electric current, producing dermal heat. They 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 1 published study has reported that treatment was well-tolerated and that 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 definitive studies are lacking.[27][28]
- Other devices used have included microdermabrasion [29], galvanopuncture [30], needling [31], pulsed magnetic fields [27], and ultrasound devices.[32][33] (A1)
The effect of treatments is difficult to assess. For example, laser protocols use differing devices, fluence, pulse duration, spot size, treatment frequency, and treatment number. The utility of combination strategies is also unknown.[18]
Platelet-rich plasma (PRP) injections are also under investigation as a potential treatment that promotes collagen production and tissue regeneration by releasing growth factors.[34] While some studies report modest improvement in skin texture and appearance, high-quality evidence remains limited, and PRP should be considered an adjunct rather than a first-line therapy.(B2)
When using any of these modalities, it is important to have standardized pretreatment and posttreatment photographs. Furthermore, it is important to take these photographs 6 and 12 months after the course of treatments. Many published reports do not have standardized photographs, nor do they have long-term follow-up.
Differential Diagnosis
When evaluating striae distensae, it is essential to consider a range of differential diagnoses that may present with similar linear or atrophic skin changes. Accurate identification of these conditions ensures appropriate management and helps rule out underlying systemic or dermatologic disorders.
Differential diagnoses include the following:
- Anetoderma
- Cutis laxa
- Linear focal elastosis
- Mid-Dermal elastosis
- Pseudoxanthoma elasticum
Prognosis
The prognosis of striae distensae is generally favorable, as they are benign and do not pose a health risk. Over time, striae often fade from striae rubrae to striae albae, becoming less noticeable, though they rarely disappear completely. While their appearance can improve, especially with time or certain cosmetic treatments, effective long-term resolution is uncommon. Psychosocial distress may persist for some patients, particularly when striae are extensive or located in visible areas. Therefore, prognosis often depends as much on cosmetic and emotional impact as on the physical presence of the striae themselves.
Complications
Striae distensae are primarily a cosmetic concern and do not typically lead to physical complications; however, they can have significant psychological and emotional effects, including reduced self-esteem, body image dissatisfaction, and social anxiety. In rare cases, aggressive or inappropriate treatments—such as overuse of topical steroids, invasive procedures, or unregulated cosmetic products—can lead to skin irritation, scarring, or infection. Additionally, striae may occasionally indicate underlying endocrine disorders, such as Cushing syndrome, requiring further evaluation. Therefore, proper assessment and cautious treatment planning are essential to avoid harm and address any underlying conditions.
Consultations
Consultations in the management of striae may involve dermatologists for expert evaluation, diagnosis, and discussion of advanced treatment options such as laser therapy or microneedling. Endocrinologists may be consulted if striae are atypical, extensive, or suggest an underlying hormonal disorder like Cushing syndrome. Mental health professionals can also provide support when striae contribute to significant psychological distress. Interprofessional collaboration ensures comprehensive care tailored to both the physical and emotional needs of the patient.
Deterrence and Patient Education
Deterrence and patient education for striae distensae should focus on addressing modifiable risk factors and promoting evidence-based preventive strategies. Physicians should advise patients on the importance of gradual weight changes, adequate hydration, and a nutrient-rich diet, particularly vitamins C and E, to support skin health and dermal elasticity. Caution should be exercised when prescribing topical or systemic corticosteroids, with clear guidance on appropriate use to avoid dermal atrophy. While no intervention has been conclusively proven to prevent striae, recommending regular moisturization and sun protection may help maintain skin integrity. Clear, evidence-informed communication can help manage patient expectations and reduce the pursuit of ineffective or harmful treatments.
Enhancing Healthcare Team Outcomes
Effective management of striae distensae requires a coordinated, patient-centered approach involving physicians, advanced practitioners, nurses, pharmacists, and other health professionals. Clinicians must possess strong diagnostic skills to differentiate striae from other dermatoses and identify underlying causes, such as endocrine disorders, that may require further evaluation. Strategies should include evidence-based education to help patients understand the benign nature of striae, the limited efficacy of treatments, and the potential risks of cosmetic interventions. Ethical responsibilities involve transparent communication, avoiding overtreatment, and supporting informed decision-making. Nurses play a key role in reinforcing education and monitoring patient concerns, while pharmacists can counsel on the appropriate use of topical agents and warn against unproven or harmful products.
Interprofessional communication is essential to ensure consistent messaging, prevent redundant or contradictory advice, and coordinate care when specialty referrals, such as dermatology, endocrinology, or behavioral health, are needed. By aligning efforts across disciplines, the care team can improve patient safety, reduce unnecessary interventions, address psychosocial impacts, and enhance both individual outcomes and team performance.
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References
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Level 2 (mid-level) evidence