JCAS_118_17

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Review Article

Management of stretch marks (with a focus on striae rubrae)

Uwe Wollina, Alberto Goldman1
Department of Dermatology and Allergology, Academic Teaching Hospital Dresden, Dresden, Germany, 1Clinica Goldman, Porto Alegre/ RS, Brazil

Abstract
Stretch marks are one of the most common benign cutaneous lesions and encountered esthetic problems. Striae rubrae and striae albae
can be differentiated on the basis of clinical appearance. Histologically, disturbances of the dermal fiber network and local expression
of receptors for sexual steroids have been detected. The epidermal changes are secondary. Prevention of stretch marks using topical
ointments and oils is debatable. Treatment of striae rubrae by lasers and light devices improves appearance. Microneedling and
non-ablative and fractionated lasers have been used. This review provides an overview on current treatment options with a special
focus on laser treatments.

Keywords: Lasers, stretch marks, striae albae, striae rubrae, therapy

Introduction The disruption of elastin fiber network results in

changes in viscoelastic properties of affected skin,
Stretch marks or striae distensae (syn. striae gravidarum)
which is significantly less firm, less elastic, and less
are common cutaneous adverse reactions caused during
deformable than normal skin. Light scattering values are
pregnancy affecting approximately 50–90% of pregnant
significantly lower in stretch marks compared to adjacent
women. Stretch marks are seen in other conditions as well,
skin. Scattering values suggest an altered collagen fiber
such as rapid weight gain (obesity), muscle hypertrophy
structure in the dermis with parallel collagen bundles.[12]
(bodybuilders), endocrinopathies (such as Cushing
No difference was observed in skin barrier function and a
syndrome), breast augmentation, or as a side effect of
slight difference was observed in skin hydration between
topical corticosteroid use and abuse. They are a rare
the stretch marks and uninvolved skin. Diffuse reflectance
complication when using tissue expanders. Stretch marks
spectroscopy showed no differences in the apparent
are most commonly seen on thighs, abdomen, female
hemoglobin concentrations between stretch marks and
breasts, and upper arms in males.[1-6]
controls.[13] Skin pigmentation is significantly lower in
In pregnant women, independent predictors of stretch stretch marks compared to adjacent skin.[12]
r marks have been identified: Younger age, maternal and
Immunohistochemical studies suggested a significant
family history of stretch marks, increased pre-pregnancy
increase of estrogen, androgen, and glucocorticoid
and predelivery weight, increased birth weight, and the
receptors in stretch marks.[14] Pregnant women with
absence of chronic disease.[7-9] In pregnant women, itching
stretch marks have lower serum relaxin levels compared
stretch marks may be a sign of herpes gestationis.[10]
to those without stretch marks at 36th gestational
Histological studies argue for a primary disruption of the week, 330.8 ± 175.2 vs. 493.8 ± 245.8 pg/mL (P = 0.037).
normal elastic fiber network. Instead of normal fibrils, However, there is no correlation between the severity of
short, disorganized, thin, threadlike fibrils emerge in the stretch marks and serum relaxin levels.[15]
mid-to-deep dermis. These fibrils are rich in tropoelastin
and persist into the postpartum period without forming Address for correspondence: Uwe Wollina, MD,
normal-appearing elastic fibers. This is accompanied by Department of Dermatology and Allergology, Academic Teaching Hospital
Dresden, Friedrichstr. 41, 01067 Dresden, Germany.
increased gene expression of tropoelastin and fibrillin-1.[11] E-mail: wollina-uw@khdf.de

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DOI: How to cite this article: Wollina U, Goldman A. Management of

10.4103/JCAS.JCAS_118_17 stretch marks (with a focus on striae rubrae). J Cutan Aesthet Surg
2018;10:124-9.

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Wollina and Goldman: Management of stretch marks

There is a characteristic feature of maturation of stretch substantiated by a study performed in South Africa and
marks, which emerge as striae rubrae but eventually shift Germany with one to four treatments.[29] Microneedling
to striae albae. Although striae rubrae are erythematous, therapy was more efficient than microdermabrasion with
sometimes edematous, striae albae are depressed atrophic phonophoresis in the treatment of stretch marks.[30]
scars with wrinkling surface.
A pilot study with tripolar radiofrequency device for
Treatment targets are dermal collagen production, 1 week suggested a reduction in the severity of stretch
vascularity (in striae rubrae), wrinkling, and roughness of marks in women.[31]
skin.[16]
In a comparative trial, 22 men and women with abdominal
striae were included. The abdomen was divided into four
Available Treatments equal quadrants. Bipolar radiofrequency potentiated with
Prevention of stretch marks infrared light and fractional bipolar radiofrequency were
A number of topical treatments has been advertised for the applied, alone or in combination, and one quadrant was
prevention of stretch marks. In a critical review, Korgavkar left untreated. Of the 384 striae that were measured, the
and Wang[17] concluded that there is limited evidence that mean depth was decreased by 21.6% at 6 month follow-up
centella, and possibly massage with bitter almond oil, with the combined approach. The width of stretch marks
may prevent stretch marks. Weak evidence is present for was not affected by any treatment. Histologically, thicker
the use of topical hyaluronic acid. A controlled trial with collagen fibers were noted after treatment.[32]
olive oil and Saj® cream demonstrated that neither of All these studies support the fact that any type of
these interventions could prevent stretch marks during controlled damage or lesion mainly in early striae can
pregnancy.[18] Other authors came to the conclusion that improve their aspect. They also support our results using
topical treatments are unable to prevent stretch marks.[19-21] laser energy as alternative in the treatment.

Reduction of severity of stretch marks with non-laser Laser-based Treatments

approaches
Several treatments have been proposed in an attempt
In general, early stretch marks, i.e., striae rubrae, respond
to obtain esthetic improvement of striae. Depending
better to treatment than the older lesions, i.e., striae
on their extent, location, and the personal perception
albae. Therefore, we focus on early stretch marks unless
of the patients, stretch marks may cause great esthetic
otherwise mentioned.
dissatisfaction and have a profound negative impact
A randomized, double-blind, placebo-controlled study on their self-esteem. Laser therapy has represented a
in pregnant women indicates that the severity of stretch breakthrough in the approach to striae, in particular striae
marks can be reduced by topical application of emollient rubrae.
and moisturizer containing hydroxyprolisilane C, rose
The natural course of stretch marks argues for an
hip oil, Centella asiatica triterpenes, and vitamin E.[22]
increased vascularity in the early lesions (striae rubrae).
It seems that moisturizers are the critical component of
Hence, here, vascular lasers should have a beneficial effect,
topical preparations for the treatment of stretch marks
as hemoglobin is working as a chromophore for specific
and it is questionable, if there is an add-on effect of other
lasers acting in this vascularity.
ingredients.[23]
The 585-nm pulsed dye laser with a 10-mm spot size
In a prospective randomized open trial, microdermabrasion
using 3.0 J/cm2 fluence improved the appearance of striae
was found to be as effective as the daily application of
in a small study. Histologic evaluation argued for the
topical 0.05% tretinoin cream in the reduction in the
restoration of normal elastin fiber network.[33] The effect
severity of early stretch marks.[24] Microdermabrasion in
has been scored as moderate for striae rubrae, but there is
combination with topical platelet-rich plasma was found
no beneficial effect on striae albae.[34] Other groups observed
to be more effective in reducing stretch mark severity than
some beneficial effects using the flashlamp-pumped pulsed
the single component.[25] To enhance penetration of topical
dye laser (585 nm). Striae width was decreased and skin
tretinoid cream, ablative radiofrequency was combined
texture was improved. Collagen expression was increased
with ultrasound. In a pilot trial, striae albae improved by
with the exception of collagen I.[35] In ethnic skin (skin
this combined approach.[26]
types 4–6), such treatment should be avoided because of
In a pilot study with 16 females, noninvasive multipolar-pulsed the risk of permanent pigmentary changes.[36]
electromagnetic field and radiofrequency energy–generating
The copper bromide laser (577–511 nm) has been
treatment resulted in some improvement in the length and
evaluated in an Italian pilot trial for female patients,
widths of stretch marks.[27]
Fitzpatrick phototype II–III, with a 2-year follow-up. The
Microneedling improved early and late stretch marks in a authors described a mild beneficial clinical and histologic
pilot study carried out among Korean women.[28] This is effect on stretch marks.[37]

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Wollina and Goldman: Management of stretch marks

Three treatments carried out 6 weeks apart with a 1450-nm The 2940-nm Er:YAG ablative fractional laser can be
diode laser, 6-mm spot size, fluence between 4 and 12 J/cm2, combined with other treatment modalities to improve striae
and dynamic cooling device, to protect the epidermis, did albae. In a study with 30 females with stretch marks, ablative
not result in any improvement of stretch marks.[38] laser was applied 6 times at 4-week intervals. This treatment
was followed by topical application of recombinant
A trial with the 1064-nm long-pulsed neodymium-doped
bovine basic fibroblast growth factor for 1 week. This was
yttrium aluminium garnet (Nd:YAG) laser, spot size
followed by red light-emitting diode once every week for
of 2.5 mm, fluence of 80–100 J/cm2, and a frequency
three sessions between the two laser treatments. Clinical
of 2 Hz in 20 patients with striae rubrae resulted in
improvement was noted for up to 12 months posttreatment.
excellent results in 40% (physician’s assessment) and 55%
Post-procedural skin biopsies demonstrated an increase
(patient’s assessment) [Figures 1-4]. The average number
in epidermal and dermal thickness, collagen, and elastin
of treatments carried out 3 to 6 weeks apart was 3.5.
density compared to baseline.[43]
Observed side effects were mild and temporary such as
minimal edema and erythema, which lasted from a few In a comparative trial, patients with striae albae treated
hours to a maximum of 3 days.[39] with either 1550-nm fractional Er:glass laser or ablative
fractional CO2 laser achieved clinical and histologic
In a trial with 45 patients, efficacies of two fluences (75 and
improvement.[44] A smaller group of patients with striae
100 J/cm2) of long-pulsed Nd:YAG laser on stretch marks
rubrae after breast augmentation also benefited from the
were compared. Spot size was 5 mm, pulse duration was
1550-nm Er:glass laser.[45]
15 ms. Clinical and histological evaluation was performed
3 months after treatment. A significant improvement in the Treatment of stretch marks in Asian women with a
appearance of striae albae was seen with 100 J/cm2 fluence, 1550-nm fractional laser improved stretch marks clinically.
whereas striae rubrae showed a better improvement with Skin elasticity was found to be partially normalized. Skin
75 J/cm2. Histologically, the dermal content of both biopsies argued for a significant increase in epidermal
collagen and elastin fibers increased.[40] thickness, collagen, and elastic fiber deposition after
fractional laser therapy. Adverse effects included mild and
A trial comparing the efficacy of 1064-nm long-pulsed
transient pain and hyperpigmentation.[46] The Er-doped
Nd:YAG laser and 2940-nm variable square pulse
fractionated 1550-nm laser has been recommended for the
erbium yttrium aluminium garnet (Er:YAG) laser in
treatment of stretch marks in a consensus conference.[47]
the treatment of striae albae could produce histological
improvement but no significant clinical improvement with Ten women with stretch marks (striae albae) and
either treatment modalities.[41] A variable square pulse Fitzpatrick skin types III–V were treated with non-ablative
Er:YAG laser resurfacing was performed in 21 women 1540-nm fractional laser four times at 4-week intervals.
of Fitzpatrick phototype ≥III with short pulse or smooth The fluence was 50–70 J/cm2. There was a clinically
mode twice with an interval of 4 weeks in between. Skin appreciable improvement in striae ranging from 1% to 24%.
roughness, skin smoothness, and surface of stretch marks Three months after the final treatment, patients showed
improved by both the modes. An adverse event in ethnic noticeable improvement in the striae, when compared with
skin is hyperpigmentation lasting as long as half a year.[42] baseline. Mild post-inflammatory hyperpigmentation was
observed in a single patient.[48] This laser type has also been

Figure 1: Striae gravidarum in the abdomen. Before (a) and after (b) single
session of 1064-nm long-pulsed Nd:YAG laser Figure 3: Breast striae after cosmetic augmentation. Before (a) and after
(b) two sessions of 1064-nm long-pulsed Nd:YAG laser

Figure 2: Stretch marks in the breast in a 17-year-old patient. Before Figure 4: Stretch marks in the abdominal region. Before (a) and after
(a) and after (b) two sessions of 1064-nm long-pulsed Nd:YAG laser (b) two sessions of 1064-nm long-pulsed Nd:YAG laser

      
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Wollina and Goldman: Management of stretch marks

used successfully in patients with stretch marks because of CO2 laser only. The investigators scored the efficacy of
topical corticosteroids.[49] combined treatment as higher without any increase in
unwanted side effects.[54]
A non-ablative fractional 1565-nm laser was used in 12
Caucasian patients with stretch marks. All participants In another trial, 40 patients with stretch marks were
achieved three treatments. Good clinical improvement treated with fractional CO2 laser or intense pulse light.
(between 51% and 75%) was observed in all patients. Most The CO2 laser worked faster and was more effective.[55]
patients showed improvement in the volume of depressions
In our opinion, the fractional CO2 laser represents the first
and in lesion color. The average downtime was 4 days.[50]
option in the treatment of striae albae. Unfortunately, the
A small study compared non-ablative fractionated lasers results are poor and the improvement very limited. We also use
of 1540 and 1410 nm. Nine patients were treated with Er:YAG laser here, but the results are limited and the redness
six laser sessions with intraindividual comparison. In all aspect consequent to laser action lasts a very long period.
patients, a clinical improvement was seen. Histologically, Limited experience exists with the use of fractional Er:YAG
increased epidermal and dermal thickness, and collagen laser.[56]
and elastin density were seen compared to baseline.
Clinical and histopathological differences between the In conclusion, laser therapy of early stretch marks (striae
two wavelengths were comparable.[51] rubrae) targets vessels. The treatment of early and later
(striae albae) stretch marks aims to increase collagen
A non-fractional 1550-nm laser was used for the treatment production, restore elastin fibers, and epidermal thickness.
of abdominal striae rubrae and striae albae in 16 females. Skin texture improvements also contribute to clinical
They were treated with five sessions at 1-month intervals. effects of laser therapy.[57-60] The number of studies with at
The mean width and length of striae decreased with a least 20 patients is limited, and placebo-controlled studies
more pronounced effect on length. There was a further have not been published [Table 1].
improvement from 1 month after treatment to 1 year
follow-up.[52] Discussion
Fractional 10,600-nm CO2 laser was effective in striae albae Stretch marks are common. They can affect both men
in patients of skin type III and IV. The laser parameters and women, but are more frequent among women.
were as follows: fluence 16 J/cm2, dot cycle 2, pixel pitch Although they rarely cause medical problems, stretch
0.8 mm. The treatment was performed in five sessions with marks are considered a major esthetic concern and have
two passes, 2 to 4 weeks apart. The clinical improvement negative impact on self-esteem and quality of life of an
was significantly better than topical treatment with 0.05% individual.[1,5]
tretinoin cream and 10% glycolic acid peels.[53]
The typical appearance of early stretch marks is redness
In a pilot trial, 44 striae albae were treated with a combined and some edema, whereas matured stretch marks are
approach using fractional CO2 laser and pulsed dye linear type of atrophic scars. The clinical response to any
laser and compared to 44 lesions treated with fractional treatment is better in early stretch marks.

Table 1: Laser therapy of stretch marks (studies with at least 20 patients included)
Laser type Comparison Study type N Outcome Reference
585-nm pulsed dye IPL Side by side 20 Improvement better in striae rubrae both Shokeir et al. 2014
treatments effective
585-nm pulsed dye with Open 37 89.2% of patients rated the outcome “good” Suh et al. 2007
Thermage or better
585-nm pulsed dye Open 20 Moderate beneficial effect on striae rubrae Jiménez et al. 2003
1,064-nm long-pulsed Open 20 55% of patients rated the outcome Goldman et al. 2008
Nd:YAG “excellent”
1,064-nm long-pulsed Open 45 Significant improvement in appearance Elsaie et al. 2016
Nd:YAG
1,540-nm Er:glass Open 51 ≥50% improvement for all patients after de Angelis et al. 2011
6 months
1,550-nm Er-doped Open 20 Moderate improvement in 63% of patients Stotland et al. 2008
fractional
2,940-nm variable square Open 21 Significant volume reduction of stretch Wanitphakdeedecha et al.
pulsed Er:YAG- marks after 6 months 2017
10,600-nm CO2 fractional Retrospective 27 Improvement after a single treatment Lee et al. 2010
10,600-nm CO2 fractional IPL Open 40 Improvement better than with pulsed light El Taieb and Ibrahim 2016
IPL = Intense pulsed light

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Wollina and Goldman: Management of stretch marks

Topical treatments have only mild effects. It is questionable, 6. Chan WY, Akhtar S, Phipps AR. Striae distensae in tissue-expanded
if creams and ointments with “specific ingredients” exert skin in the upper arm. Ann Plast Surg 2006;57:240-1.
7. Farahnik B, Park K, Kroumpouzos G, Murase J. Striae
a significant and better improvement than moisturizers. gravidarum: Risk factors, prevention, and management. Int J
Topical treatment cannot prevent the occurrence of stretch Womens Dermatol 2017;3:77-85.
marks under specific circumstances such as pregnancy.[16-23] 8. Kasielska-Trojan A, Sobczak M, Antoszewski B. Risk factors of
striae gravidarum. Int J Cosmet Sci 2015;37:236-40.
Laser treatment is a physical tool used in the improvement 9. Chikvaidze N, Kristesashvili J, Gegechkori M. Peculiarities of
of stretch marks with a focus on early stretch marks sexual development and reproductive function in young women
with childhood onset weight problems. Georgian Med News
[Table 1]. Owing to its physical characteristics, represented 2014;235:11-6.
mainly by the 1064-nm wavelength and dye pumped laser, 10. Wollina U, Degen KW, Konrad H, Schönlebe J. Itching stretch
these lasers are very safe. Complications are rarely produced marks and bullous lesions in a pregnant woman. Int J Dermatol
when the device and parameters are appropriately utilized, 2004;43:752-4.
11. Wang F, Calderone K, Smith NR, Do TT, Helfrich YR, Johnson
even in patients with dark skin. In addition, the cooling of TR, et al. Marked disruption and aberrant regulation of elastic
the striae before and immediately after the use of the laser fibers in early striae gravidarum. Br J Dermatol 2015;173:1420-30.
represents yet another factor in epidermal protection. 12. Stamatas GN, Lopes-DaCunha A, Nkengne A, Bertin C. Biophysical
properties of striae distensae evaluated in vivo using non-invasive
Such cooling of the treated areas, however, should not
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be too long so as to avoid local vasoconstriction and the 13. Bertin C, Lopes-DaCunha A, Nkengne A, Roure R, Stamatas
consequent decrease of the chromophore oxyhemoglobin. GN. Striae distensae are characterized by distinct microstructural
The treatment of erythematous striae using the 1064-nm features as measured by non-invasive methods in vivo. Skin Res
Technol 2014;20:81-6.
long-pulsed Nd:YAG laser demonstrated clinical 14. Cordeiro RC, Zecchin KG, de Moraes AM. Expression of estrogen,
improvement of such lesions, probably due to the laser’s androgen, and glucocorticoid receptors in recent striae distensae. Int
affinity toward the vascular target present in the striae. The J Dermatol 2010;49:30-2.
absorption of the laser by its target, i.e., oxyhemoglobin, 15. Lurie S, Matas Z, Fux A, Golan A, Sadan O. Association of serum
relaxin with striae gravidarum in pregnant women. Arch Gynecol
leads to an improvement in the redness. In addition, it Obstet 2011;283:219-22.
has become evident that, like other luminous sources, the 16. Hague A, Bayat A. Therapeutic targets in the management of striae
long-pulsed Nd:YAG laser also induces the formation of distensae: A systematic review. J Am Acad Dermatol 2017;77:
new collagen; this leads to an improvement in the atrophy 559-568.e18.
17. Korgavkar K, Wang F. Stretch marks during pregnancy: A review of
of the skin and consequently, improves the appearance of topical prevention. Br J Dermatol 2015;172:606-15.
immature striae. This improvement was evident for both 18. Soltanipour F, Delaram M, Taavoni S, Haghani H. The effect of
the patients and doctors.[35,39] The full clearance of the olive oil and the saj® cream in prevention of striae gravidarum: A
lesions is very rare and seems to be occasionally obtained randomized controlled clinical trial. Complement Ther Med
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20. McAvoy BR. No evidence for topical preparations in preventing
Declaration of patient consent stretch marks in pregnancy. Br J Gen Pract 2013;63:212.
The authors certify that they have obtained all 21. Brennan M, Young G, Devane D. Topical preparations for
appropriate patient consent forms. In the form the preventing stretch marks in pregnancy. Cochrane Database Syst Rev
2012;11:CD000066.
patient(s) has/have given his/her/their consent for his/ 22. García Hernández JÁ, Madera González D, Padilla Castillo M,
her/their images and other clinical information to be Figueras Falcón T. Use of a specific anti-stretch mark cream for
reported in the journal. The patients understand that preventing or reducing the severity of striae gravidarum. Randomized,
their names and initials will not be published and double-blind, controlled trial. Int J Cosmet Sci 2013;35:233-7.
23. Rawlings AV, Bielfeldt S, Lombard KJ. A review of the effects of
due efforts will be made to conceal their identity, but moisturizers on the appearance of scars and striae. Int J Cosmet Sci
anonymity cannot be guaranteed. 2012;34:519-24.
24. Hexsel D, Soirefmann M, Porto MD, Schilling-Souza J, Siega C,
Dal’Forno T. Superficial dermabrasion versus topical tretinoin on
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      Journal of Cutaneous and Aesthetic Surgery ¦ Volume 10 ¦ Issue 3 ¦ July-September 2017 129  
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