Cosmetic Dermatology

Interventions for the Treatment of Stretch Marks: A Systematic Review

Cutis. 2014 August;94(2):66-72

References

1. Viennet C, Bride J, Cohen-Letessier A, et al. Mechanical behavior of fibroblasts included in collagen lattices. J Soc Biol. 2001;195:427-430.

2. Chang AL, Agredano YZ, Kimball AB. Risk factors associated with striae gravidarum. J Am Acad Dermatol. 2004;51:881-885.

3. Salter SA, Kimball AB. Striae gravidarum. Clin Dermatol. 2006;24:97-100.

4. Elsaie ML, Baumann LS, Elsaaiee LT. Striae distensae (stretch marks) and different modalities of therapy: an update. Dermatol Surg. 2009;35:563-573.

5. Singh G, Kumar LP. Striae distensae. Indian J Dermatol Venereol Leprol. 2005;71:370-372.

6. Jiménez GP, Flores F, Berman B, et al. Treatment of striae rubra and striae alba with the 585-nm pulsed-dye laser. Dermatol Surg. 2003;29:362-365.

7. Watson RE, Parry EJ, Humphries JD, et al. Fibrillin microfibrils are reduced in skin exhibiting striae distensae. Br J Dermatol. 1998;138:931-937.

8. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Oxford, United Kingdom: The Cochrane Collaboration; 2011. http://handbook.cochrane.org/. Accessed July 8, 2014.

9. Draelos ZD, Gold MH, Kaur M, et al. Evaluation of an onion extract, Centella asiatica, and hyaluronic acid cream in the appearance of striae rubra. Skinmed. 2010;8:80-86.

10. Kang S, Kim KJ, Griffiths CE, et al. Topical tretinoin (retinoic acid) improves early stretch marks. Arch Dermatol. 1996;132:519-526.

11. Morganti P, Palombo P, Fabrizi G, et al. Biweekly in-office injectable treatment of striae distensae vs a long-term daily use of topical vitamin C. J Appl Cosmetol. 2001;19:107-112.

12. Naein FF, Soghrati M. Fractional CO₂ laser as an effective modality in treatment of striae alba in skin types III and IV. J Res Med Sci. 2012;17:928-933.

13. Pribanich S, Simpson FG, Held B, et al. Low-dose tretinoin does not improve striae distensae: a double-blind, placebo-controlled study. Cutis. 1994;54:121-124.

14. Summers B, Lategan M. The effect of a topically-applied cosmetic oil formulation on striae distensae. SA Fam Pract. 2009;51:332-336.

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16. Yang YJ, Lee GY. Treatment of striae distensae with nonablative fractional laser versus ablative CO₂fractional laser: a randomized controlled trial. Ann Dermatol. 2011;23:481-489.

17. Joshi J, Donga SB, Pandya MA. A comparative study of Savarnakara Ghrita and Savarnakara Cream in the management of Kikkisa w.s.r. to Striae Gravidarum. Ayu. 2008;29:260-265.

Effects of Treatments

Among the 8 studies we assessed, there were different treatments, methods of comparison, product concentrations, and times of application. The methods for assessing outcomes (eg, the size and severity of stretch marks) also were varied. Therefore, it is difficult to perform a meta-analysis of the data, and all the evidence was from individual studies. A summary of the results is presented in the Table.

All of the studies we evaluated assessed clinical improvement. Three studies reported the effects of topical tretinoin on stretch marks.^10,12,13 A small parallel study with unclear risk of bias indicated that white participants with erythematous stretch marks seemed to have a better response to treatment with tretinoin cream 0.1% for 24 weeks versus placebo.¹⁰ However, there was no significant difference between tretinoin cream 0.025% and placebo for patients with abdominal striae in another trial.¹³ The latter trial was performed with low risk of bias in methodology, but the dropout rate was high (65.6%), with only 11 of 32 participants completing the trial. It is likely that the small number of patients makes the power too low to detect significant differences between tretinoin cream 0.025% and placebo if such a difference indeed existed.¹³ Because the outcomes in these 2 trials were assessed in different ways, it is difficult to perform a meta-analysis on the data. More adverse effects, mainly erythema and scaling associated with itching or burning sensations, were reported with the higher concentration (0.05%) of tretinoin.¹⁰ Another study at a high risk of bias found that the combined use of tretinoin cream 0.05% and glycolic acid 10% was not as effective as fractional CO₂ laser therapy in improving the appearance of striae alba.¹² There also were 3 studies comparing the effects of laser therapy with another treatment or no treatment.^12,15,16 Two within-participant comparison studies with unclear or high risk of bias compared CO₂ fractional laser therapy with other active treatment methods in female participants with striae alba.^12,16 No difference between the fractional CO₂ laser and the 1550-nm nonablative fractional erbium:glass laser was reported,¹⁶ but the fractional CO₂ laser may be more effective than the topical therapy.¹² A small study (11 participants) at high risk of bias reported negative results for the 1450-nm mid-infrared diode laser compared to no treatment.¹⁵ Data on the adverse effects of laser therapy were available from these studies. Postinflammatory hyperpigmentation was found in all the 3 studies^12,15,16 and posttreatment erythema was mentioned in 2 studies.^15,16 Based on the individual studies, treatment with a cosmetic oil formulation was more effective than a moisturizer in improving clinical presentation of stretch marks in white patients.¹⁴ Women with striae rubra showed better response to treatment with onion extract cream versus no treatment.⁹ Limited data from 1 study showed that combined use of Active B (sodium ascorbyl phosphate, 3-aminopropyl-L-ascorbyl phosphate, carboxybetaglucan, hyaluronic acid) and Active A (hyaluronic acid, sodium salt 2 mg, sodium carboxymethyl betaglucan 0.1 mg, ascorbic acid 0.5 mg, arginine 1 mg, sodium chloride 9 mg, sterile water) might be more effective than the use of Active B or placebo.¹¹ These 3 studies are at high risk of bias and no obvious adverse effects were reported.^9,11,14

Comment

In the 8 trials included in our assessment, 5 used a within-participant design in which 2 different treatments were randomly administered to the left and right sides of the body, respectively.^9,12,14-16 Because the comparison of treatments was made based on results in the same patient versus 2 different treatment groups, the results may be more accurate. In the studies we reviewed, only 3 were placebo-controlled, which may only provide limited evidence on the comparative efficacy of the treatments used in these studies.^10,11,13 Most treatments were evaluated in single studies, and most studies had a small number of participants (range, 6–66 participants). A considerable number of the total participants withdrew from their respective studies or were lost during follow-up. In some cases, no reason was given,¹³ but in the others, it was because of an obvious side effect¹⁶ or noncompliance.¹⁴ Overall, the methodology quality was low, especially the methods of randomization and allocation concealment. Unsuccessful attempts to contact the original investigators made it difficult to make accurate assessments of the risk of bias in most of the studies included in our assessment. No study met all the risk of bias criteria, and none were classified as having a low risk of bias.

The impact of industry sponsorship on the direction and completeness of the results of the studies we reviewed is unclear. One study was funded by a grant from the manufacturer of the study product,¹⁴ and the medication used in another study was supplied by the manufacturer.¹³ Another study was supported in part by a company that had no part in the conduct, analysis, or reporting of the study.¹⁰ In one instance, the authors were employees of the manufacturer of the study product.⁹ The remaining studies made no declaration.^11,12,15,16

Thus the evidence from this review was insufficient to provide clear guidelines for practice. Because the results were based on a small number of patients and were of high or unclear risk of bias, caution must be taken when comparing the efficacy of the treatments administered in these studies; however, given the negligible reported side effects, tretinoin cream 0.1%, a cosmetic oil formulation, onion extract cream, or the combined use of Active A and Active B could reasonably be considered for the treatment of stretch marks. Laser therapies such as the fractional CO₂ laser or the 1550-nm fractional erbium:glass laser may be another effective choice.

Conclusion

In future investigations of stretch mark treatments, more high-quality, placebo-controlled trials are needed. One important issue is the varied outcome assessment among different studies, which makes the evaluation and pooling of different studies difficult. Therefore, future RCTs should measure clinical features with a uniform score system such as the visual analog scale or the patient and observer scar assessment scale and try to avoid individual made-up system to assess the outcome. Furthermore, quality-of-life assessment was not included in any of the reports we evaluated; rather all 8 studies focused on changes in the appearance of stretch marks only. Given the deep psychological impact that stretch marks can have on patients, measures for quality-of-life assessment, such as the dermatology life quality index, should be incorporated into future study designs to improve the relevance of the trial and allow comparisons among studies using different interventions.