Commentary on Striae Distensae

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Striae distensae affect a great number of people, both adults and children alike. The resistance to treatment of stretch marks is often frustrating and disappointing to both patients and physicians. Thus, of great interest, Ross and colleagues1 present a thorough and comprehensive review of the published literature and the available treatment modalities that may serve as an up-to-date reference for clinicians.
Historically, although many therapies for striae have been tried, the results are often modest. This may be in part because the wound remodeling capacity of skin is simply not robust enough to overcome the magnitude of damage to collagen and elastin fibers when skin is stretched beyond its capacity for recoil. This may be particularly so on the trunk where the vascular supply is limited and wound healing slower compared with facial areas. Despite these limitations, patients often welcome some degree of improvement when clearance is not possible.
The FDA approval of a 1,540 nm nonablative fractional resurfacing laser (Lux1540; Palomar Medical Technologies, Inc., Burlington, MA) for the improvement of striae in 2010 was promising (Figure 1), and opened the door for a number of laser, light, and energy-based devices to further explore the treatment of striae. Although not FDA approved for this indication, a variety of resurfacing devices are used to treat striae, including ablative and nonablative fractional resurfacing lasers.2 Although a variety of patterns of thermal injury may be created using different parameters of various devices, wound healing responses may be less unique. The magnitude of thermal injury relative to surrounding reservoirs of wound healing may have the greatest impact and more relevance.
In practice, laser surgeons tend to become proficient with the devices they have for a variety of indications, striae included. And so, the exploration and progression of off-label use continues. Interestingly, both fractional erbium and carbon dioxide resurfacing lasers have demonstrated excellent results in the treatment of hemangioma residuum, another condition with a history of overly stretched skin, albeit on the face and at a younger age.3,4 Also notable is the finding of neoelastogenesis after the treatment of skin laxity with a bipolar fractional radiofrequency device with real-time thermal feed back.5 This histologic finding suggests that this device may be useful for striae; however, this has not yet been demonstrated.
For practical reasons, the choice of what device to use is often decided by what device is already owned by a practice, or which therapy may be performed most efficiently. For instance, scanning lasers are typically more efficient than stamping lasers, which tend to require a greater time commitment. Even so, multiple treatments are usually required. Patients must weigh the cost of treatment to benefits, particularly if a large area is involved. Although most striae improve some with time, early intervention with lasers is thought to be beneficial. However, most therapies and devices are not studied in children, so early intervention in this population is reserved and limited to alleviating the cause when possible.
Although the problem of striae continues to frustrate and intrigue, clinicians continue to innovate and perfect their skills, and this combination will likely continue to drive progress.
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