INTRODUCTION
Stretch marks are common linear atrophic dermatoses. Due to their non-esthetic
nature, they have psychosocial implications that interfere with a patient’s
quality of life. The prevalence is twice as high in women than in men, and it
occurs more commonly in Caucasians. Moreover, it is commonly observed during
puberty, affecting approximately 30% of individuals in this age group worldwide,
and during pregnancy, influencing around 75% of pregnant women1.
Obesity, pregnancy, rapid weight gain or loss, adolescent growth,
endocrine–metabolic syndromes, and prolonged exposure to corticosteroids are
the
factors associated with the development of stretch marks. However, its
etiological mechanism is not fully understood2.
Mechanical stretching of the skin is the most likely pathophysiological mechanism
underlying the stimulation of mast cells that release proteolytic enzymes, such
as elastases. This phenomenon leads to the elastolysis of existing elastic and
collagen fibers and the decrease in fibroblast activity during high-quality
synthesis of the extracellular matrix, culminating in the reorganization of the
matrix and its fibers, and to a significant deficit in collagen and elastin
fibers, thereby contributing to the atrophic appearance of stretch marks.
Initially, stretch marks present as erythematous and edematous linear plaques due
to the inflammatory process triggered by the distension and degeneration of
elastic fibers and degranulation of mast cells, characterizing the so-called
immature striae or striae rubra. Over time, these striae undergo a maturation
process, thereby becoming atrophic and hypopigmented, with the horizontal
arrangement of the thin bundles of dense collagen, characterizing the mature
striae or striae alba1.
Although they are not life-threatening, in terms of esthetic aspects, improving
the appearance of stretch marks is essential for the self-esteem of individuals
and adequate social interaction. However, stretch marks pose challenges in
clinical therapy, particularly in relation to the presence of striae alba. The
literature has reported several treatment modalities for stretch marks, which
include chemical peels (glycolic acid), topical medications (tretinoin),
silicone sheets, microdermabrasion, radiofrequency, phototherapy (ultraviolet
A
and B), and lasers4.
In this context, lasers, which are less-invasive methods, have shown satisfactory
results. That is, they have decreased the excessive vascularization of the
striae rubra and stimulated the production of collagen and elastin in striae
alba5.
OBJECTIVE
This study aimed to carry out a literature review on the most relevant aspects of
laser treatment for stretch marks between January 2000 and December 2016.
METHODS
The literature review only included original articles, case reports, and
systematic reviews published between January 2000 and December 2016. The
journals indexed in Public Medical Literature Analysis and Retrieval
System Online (PubMed) database were considered. The descriptors
used in searching for articles were laser treatment and
striae distensae.
RESULTS
In the initial research carried out in PubMed, 36 articles were found, of which
28 were included in the review because they discussed the treatment for
striations with a laser and they were published between 2000 and 2016. The
articles included original articles, case series, and review articles.
DISCUSSION
Non-fractional laser releases a single beam of light that disperses energy from a
central point. The fractional laser releases energy to the tissue through
multiple microscopic columns surrounded by untreated areas. This pattern of
microthermal heat zones delivers energy to the skin more evenly. It is possible
to split a beam of light in both ablative and non-ablative lasers. Ablative
lasers use long wavelengths to target the water present in both the epidermis
and dermis, thereby vaporizing the cells5.
The following are the categories of lasers for the treatment of stretch marks
that were discussed in this study:
Non-ablative lasers
308-nm Xenon Chloride (XeCl) Excimer Laser
The excimer laser classically treats hypopigmented, psoriatic, and
depigmented vitiligo lesions by means of dermal lesions that stimulate
the formation of collagen and elastin. In a randomized clinical trial,
68% of repigmentation was observed after a mean excimer laser session of
9 months6. Another study has also
evaluated the use of excimer laser in 10 patients with striae alba.
Patients underwent approximately 9 weekly sessions of laser treatment
with a fluence of 50 mJ/cm2. Laser therapy caused increased
pigmentation. However, only one patient presented with almost complete
resolution and two had moderate improvement at 26%-50%. During
follow-up, the clinical appearance of the skin returned to the initial
pattern after 6 months, which indicated the need for frequent
maintenance therapy. Excimer laser does not significantly improve
texture and remove the redness of striae rubra. Moreover, it is not a
therapeutic option for the re-pigmentation of striae alba7.
577-nm Copper Bromide (CuBr) Laser
A case series has reported that five patients achieved a complete
improvement in terms of the appearance of stretch marks, whereas 10
patients achieved 50%-90% improvement based on histologic
measurements8.
585- and 595-nm Pulsed Dye Laser (PDL)
PDL uses hemoglobin as the chromophore of the vessels. Thus, it is an
effective treatment for erythema. Its mechanism of action also
stimulates the reorganization of collagen and elastin in the skin,
thereby improving the appearance of the lesions9. However, this modality is not indicated for
patients with darker skin types since they may develop post-inflammatory
hyperpigmentation. Jiménez et al.10 have assessed the efficacy of the 585-nm PDL in 20
patients with stretch marks who received two treatments at an interval
of 6 weeks, and these patients were assessed clinically and
histologically 6 weeks after the second treatment. Only four red striae
showed changes in pigmentation after treatment. No improvement was
observed in the striae alba. However, the histological analysis revealed
an increase in collagen in both the striae alba and rubra10.
1064-nm Neodymium-doped Yttrium Aluminum Garnet (Nd:YAG)
Laser
A series of cases has shown improvement in striae rubra after
approximately four sessions, with satisfaction rated as “excellent” by
55% of the treated patients and 40% of the attending physicians11.
Another study involving 45 patients with Fitzpatrick III–V skin type (23
with striae rubra and 22 with striae alba) were treated with an 1064-nm
Nd:YAG laser with two different fluences: 75 J/cm2 and 100
J/cm2. The used spot was 5 mm, and the pulse duration was
15 ms. All patients underwent four sessions at an interval of 3 weeks.
Three weeks after the last session, the results were clinically
evaluated using photos and via biopsies. The appearance of striae alba
significantly improved with Nd:YAG long pulse laser at a fluence of 100
J/cm2, whereas the appearance of the striae rubra
improved more with a fluence of 75 J/cm2.
1410-, 1450-, 1540-, and 1550-nm Erbium:Glass (Er:Glass)
Laser
Fractional lasers release energy that penetrates the superficial dermis
producing heat columns called microthermal zones, and these are
distributed through the treated area in a dotted pattern. The preserved
areas in the skin around the dots serve as a nutritional and structural
reservoir for healing to occur more quickly5. A randomized clinical study and eight case series
on Er:glass laser were identified in this review.
The randomized clinical trial using non-ablative and non-fractionated
1450-nm Er:glass laser did not result in a significant improvement 2
months after treatment. This study examined 11 patients who underwent
treatment with three fluence settings (4.8 or 12 J/cm2)
applied in three treatment sessions for 18 weeks. No difference was
observed between the three fluence configurations in terms of
improvement in the striae. In addition, 64% of the patients presented
with post-inflammatory hyperpigmentation13.
However, case series and comparative tests using the 1410-, 1540-, and
1550-nm non-ablative fractional lasers (NAFL) of showed a greater
improvement in the appearance of the striae, and among these lasers, the
authors recommend the 1540-nm NAFL for the treatment of stretch marks. A
series of comparative cases have investigated treatment with 1540- and
1410-nm NAFL and reported significant clinical improvement when the two
laser systems were used14, and
the 1540-nm NAFL caused an even greater improvement in the striae than
the 1410-nm NAFL14.
Another case series has reported a 1%-24% improvement in the appearance
of stretch marks after four monthly sessions of 1540-nm NAFL in terms of
stria aspect, whereas two case series on striae treatment with 1540-nm
Er:Glass laser showed improvement in stretch marks after two to four
sessions15-17. Four case series and one case
report have shown a significant improvement in stretch marks after three
to eight sessions using a 1550-nm Erbium NAFL18-21. Moreover, several cases have presented good clinical
improvement in up to 75% of the treated striae, and most striae showed
improvement in texture and color22.
Based on the promising results of comparative studies and case reports on
NAFL, future research should consider conducting large-scale randomized
clinical trials to determine and establish the safety and efficacy of
NAFLs and to recommend such therapy for stretch marks.
Ablative Lasers
10600-nm CO2 Laser
Ablative lasers are effective in treating scarring as they cause ablation
in the epidermal layer and can penetrate deep into the dermis. Ablation
and tissue coagulation stimulate neocollagenesis and elastin deposition
during healing. However, treating patients with darker skin requires
caution as they are at increased risk of developing post-inflammatory
hyperpigmentation. This review found three randomized studies and two
case series that used ablative CO2 laser.
A randomized clinical trial treated 22 patients with CO2 laser
and 1550-nm Er:glass non-ablative fractional laser and reported a
significant reduction in the length and width of the stretch marks23. Three treatments with either
the 10600-nm ablative CO2 laser (40-50 mJ, spot density of
75-100 spot/cm2) or 1550-nm non-ablative fractional laser (50
mJ, 100 spot density of 100 spot/cm2) were conducted at
4-week intervals.
Another randomized clinical trial involving six patients has investigated
the improvement of stretch marks after treatment with a 10,600-nm
fractional CO2 laser compared to glycolic acid24. The mean decrease in surface
area and the mean improvement score were both higher in the group
treated with CO2 laser than in the group treated with
glycolic acid24.
A randomized comparative trial has revealed significant improvement with
only 5 sessions of fractionated CO2 laser treatment compared
to 10 sessions of intense pulsed light after 5 months, as assessed by an
evaluator who did not participate in the applications of the lasers and
by measuring the width of the stretch marks3. A different comparative randomized clinical trial
has reported that treatment with fractional CO2 laser
combined with PDL resulted in a significantly greater improvement
compared to treatment with isolated fractional CO2 laser25.
Two case series showed excellent improvement in stretch marks in terms of
aesthetics after treatment with ablative CO2 laser. The first
case series showed a 75%-100%, 50%-75%, 25%-50%, and 0%-25% improvement
in 7.4% (2 of 27), 51% (14 of 27), 3.3% (9 of 27), and 7.4% (2 of 27)
patients, respectively26.
Post-inflammatory hyperpigmentation occurred in few patients (number not
defined) and resolved within 4 weeks26.
The second case series has investigated atelocollagen succinylate
combined with CO2 ablative laser for stretch marks and
reported improved striae with such treatment27. The treatment of stretch marks with
CO2 ablative laser showed promising clinical improvements
in randomized trials and observational studies, and future research
should include randomized clinical trials with larger sample size to
develop protocols for laser configurations to maximize positive outcomes
and minimize risks, such as post-inflammatory hyperpigmentation.
2940-nm Erbium:YAG Laser
Only one case report has shown that patients prefer the cosmetic results
of the 2940-nm Er:YAG ablative laser to those of PDL28.
After conducting this review, a combined treatment with PDL and NAFL for
striae rubra and treatment with NAFL for striae alba is recommended.
Most red pigments in striae rubra are absorbed by the pulsed dye laser
or other vascular lasers. The appearance and texture of the stretch
marks can improve significantly with 1540-nm NAFL.
Due to the appearance of microthermal zones and the capability to
stimulate collagen growth, ablative and non-ablative fractional lasers
can become a promising therapy for the treatment of stretch marks since
they aid in the remodeling of the extracellular matrix, including
collagen and elastin14,29. The
increase in the amount of reorganized, remodeled, normalized, and
healthy elastin fibers in the dermis was associated with the clinical
improvement in the appearance of stretch marks30,31.
Recent studies have shown that non-ablative fractional laser can obtain
better results in treatment of stretch marks, in addition to recovery
being earlier than with ablative lasers. In relation to these reasons,
the 1540-nm non-ablative fractional laser showed interesting therapeutic
modality as a front-line treatment of stretch marks. However, larger
studies must be conducted to standardize doses and protocols.
Future studies should focus on improving study design, including a larger
sample size, a randomized long-term comparative study with objective
outcome measures, such as skin biopsy results, and molecular studies
showing increased collagen and elastin fibers correlating to clinical
improvements.
CONCLUSION
The prevention and treatment of stretch marks remain a clinical challenge as
evidence by the different alternative methods that are available. Limitations
include the few randomized clinical trials that have evaluated the long-term
efficacy and safety of the different treatment modalities using universally
validated standardized assessment methods.
Non-ablative fractional lasers, particularly 1540-nm lasers, are interesting
therapies for the stretch marks.
COLLABORATIONS
|
ACN
|
Analysis and/or interpretation of data; statistical analysis; final
approval of the manuscript; data collection; study design; project
management; research; methodology; writing: preparation of the
manuscript; writing: revision and editing; supervision; validation;
and visualization.
|
|
LCS
|
Analysis and/or interpretation of data; final approval of the
manuscript; data collection; investigation; writing: preparation of
the original; writing: revision and editing; validation; and
visualization.
|
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1. Pontifícia Universidade Católica de Campinas,
Campinas, SP, Brazil.
Corresponding author: André Coelho Nepomuceno, Av. Dr. José
Bonifácio Coutinho Nogueira, nº 214, Sala 435 - Jd. Madalena - Campinas, SP,
Brazil, Zip Code 13.091-611. E-mail:
andreconep@yahoo.com.br
Article received: July 26, 2018.
Article accepted: November 11, 2018.
Conflicts of interest: none.
