Summary

Many things change after you have a baby: schedules, sleep time, and a sense of freedom, to name a few. Along with, there are many physical changes you’ll see. Chief among them is stretch marks. Stretch marks or striae are a form of scarring on the skin with an off-color hue. Stretch Marks are the result of the dermal tear, which over time may diminish, but will not disappear completely. Stretch marks are often the result of the rapid stretching of the skin associated with rapid growth or rapid weight changes. Stretch marks may also be influenced by hormonal changes associated with puberty, pregnancy, bodybuilding, hormonal replacement therapy, etc. Stretch marks formed during pregnancy, usually during the last trimester. It generally appears on the belly and commonly on the breasts, thighs, hips, lower back, and buttocks. For the treatment of red stretch marks, clinicians may consider the PDL, 1,064-nm Nd: YAG laser, and 532-nm KTP laser, which would likely improve the redness (vascular component) of red stretch marks. Recently, several emerging treatment modalities, including fractionated micro-needling RF, ultrasound, and PRP and micro-needling, have reported good clinical improvement of stretch marks. Stretch marks prevention and treatment stay a clinical challenge. Physicians should set realistic expectations with patients seeking stretch marks treatment and informing patients that the appearance and texture of stretch marks may improve but will not completely resolve to be an integral part of setting these expectations.

[rev_slider alias="stretch-marks-treatment"][/rev_slider]

Many things change after you have a baby: schedules, sleep time, and a sense of freedom, to name a few. Along with a changing plan, there are many physical changes you’ll see. Chief among them is stretch marks. For many women, stretch marks are a part of having a baby as diapers and feedings. Stretch marks or striae are a form of scarring on the skin with an off-color hue. Stretch Marks are the result of the dermal tear, which over time may diminish, but will not disappear completely. Stretch marks are often the result of the rapid stretching of the skin associated with rapid growth or rapid weight changes. Stretch marks may also be influenced by hormonal changes associated with puberty, pregnancy, bodybuilding, hormonal replacement therapy, etc. Stretch marks formed during pregnancy, usually during the last trimester. It generally appears on the belly and commonly on the breasts, thighs, hips, lower back, and buttocks.

Symptoms and Signs of Stretch Marks

They first appear as reddish or purple lines but tend to fade to a lighter range. If you have a brighter complexion, you will manage to develop pinkish stretch marks. Darker-skinned women tend to get stretch marks that are lighter than their skin tone. The affected areas appear empty and are soft to the touch. Stretch marks occur in the dermis, the resilient middle layer that helps the skin keep its shape. Stretching alone is not the cause. However, stretching plays more of a role in where the marks occur and in what direction they run. Stretch marks can appear anywhere on the body but are most likely to appear in places where more significant amounts of fat are stored. The most common sites are the abdomen, breasts, upper arm, underarms, back, thigh, hips, and buttocks.

Who Gets Stretch Marks?

If you have them, you are in good company. According to the American Academy of Dermatology, about 90% of women will get them sometime after their sixth or seventh month of pregnancy. If your mother had stretch marks, you are more likely to have them, too, since genetics plays a role. Several causes promote the appearance of stretch marks, low maternal age, high body mass index, weight gain over 15 kg, and higher neonatal birth weight were independently associated with the occurrence of striae. Teenagers are at the highest risk of developing severe striae.  The glucocorticoid hormones responsible for developing stretch marks affect the dermis by preventing the fibroblasts from forming collagen and elastin fibers, necessary to keep rapidly growing skin taut.  Skin subjected to more stretching force than it can handle will tear—hormonal changes, genetics, diet, and exercise influence the skin’s ability to withstand stretching forces. How quickly you gain may be as important as how much you gain when it comes to stretch marks.

Is Stretch Marks Prevention Possible?

Unfortunately, there is no way to prevent stretch marks.   No cream, lotion, or “mommy” balm that can do that — and if that is the claim on the bottle, do not be fooled, Prof. Moawad says.  It is always a good idea to keep your skin hydrated with a creamy lotion or cream, especially if it makes your skin feel better, look smoother and more toned, and helps the itchiness that can come with your growing belly. It also helps to keep your body hydrated with water. While some stretch marks naturally fade to faint, silvery lines, others stay darker and showier. The best time to treat the marks, Prof Moawad says, is while they are still in that reddish stage.

Stretch Marks Treatment. Options

Various treatments are available for improving the appearance of existing stretch marks, including topical treatment, microdermabrasion, micro-needling, chemical peels, laser treatments, Light sources,  and radiofrequency. Gentler processes such as micro-dermabrasion can also help renew the skin, but do not expect a significant change. A new modality, fractional laser resurfacing, offers a novel approach to treating striae. Scattered pulses of light will zap a fraction of the scar throughout several treatments. This creates microscopic wounds. The body responds to each treatment by producing new collagen and epithelium. Additional in-office treatments include lasers that heat the skin (nonablative or sub-ablative). The long-pulsed Nd YAG 1320nm or similar mid-infrared lasers such as 1450nm or 1540nm boost collagen growth without injuring the epidermis and shrinks dilated blood vessels offer a gentler approach. However, it may take several sessions to see results.

Silicone Dressing

Another treatment modality used that focuses on hypertrophic scars, and to a lesser degree, the keloid is silicone dressing. There is variable support to the silicone itself, with results more likely attributable to occlusion or hydration. The pressure-supported mechanism and other rationales include temperature, increased oxygen tension, electrostatic properties, or immunologic effects. Although the mechanism of action of silicone elastomer sheeting has not been elucidated, it is an effective means of treating and preventing hypertrophic and keloid scars.  As STRETCH MARKS are a form of dermal scarring, silicone gels and occlusive bandages share a similar mechanism as that proposed for scar treatment.

Chemical Peels

Chemical peels induce modulation of collagen.  Patients treated with 50% trichloroacetic acid (TCA) peel up to 8 peels. Combination chemical peels for the treatment of STRETCH MARKS have modest results. Prof Moawad recommends A 70% glycolic acid and 35% trichloroacetic acid (TCA)for improving the surface appearance of STRETCH MARKS.

Micro-dermabrasion

Micro-dermabrasion uses physical agents, typically aluminum oxide, for skin resurfacing. This injury incites new collagen formation and elastin deposition and disrupts adjuvant topical therapies to effectively penetrate the dermis.  Micro-dermabrasion is useful in the treatment of facial scarring. Micro-dermabrasion is a usually painless, superficial treatment with more texture benefits than permanent surface change. Micro-dermabrasion showed better results with fewer treatment sessions when combined with PRP.

Microneedling and MicroInjection

The dermal roller is a choice for those suffering from open pores, acne scars, fine wrinkles, stretch marks, and even hair loss. Micro-needling works by applying a device that has multiple fine needles to the surface of the skin.  This action induces fine shallow punctures on the skin, and these micro-wounds will promote the healing process. When the needle breaks the healthy skin barrier, blood vessels will be injured, thus releasing many repair cells in the blood. This repairing process will also stimulate collagen and elastin synthesis giving the tightening after effect. The procedure is done by applying a numbing cream to the skin first to be comfortable throughout the process. The after-effects of this procedure are redness of the skin with mild swelling that will resolve in several hours. Micro-needling is an excellent treatment to be combined with mesotherapy, electro-poration, or PRP for an enhanced effect. You can keep your derma-roller to enhance the impact of prescribed home skincare products further. Micro-needling treatment of stretch marks showed subjective improvement.

Subcision

A tri-bevel needle is probed under the lesion through the needle’s puncture, so it is not an exact incision. This movement results in the release of papillary skin from the binding connections of the deeper tissues. It creates controlled trauma that leads to wound healing and associated added connective tissue formation in the treated location. Performing variable depths of sweeping, fanning, or lancing may be necessary to disrupt the fibrous connections. Intradermal insertion is suitable for small superficial scars, while deeper dermal undermining is performed for more severely bound-down scars. It has become a first-line treatment for many isolated, moderately bound down, atrophic scars. A combination of subcision and nonablative laser suggested a synergistic effect between these modalities. Multiple attempts or sessions may be required. Subcision may produce unfavorable results, and therefore is not recommended.

Energy-based Therapies

Nonablative therapies include multiple wavelength lasers, pulsed light, and other forms of energy delivery.  There is selective thermal stimulation of dermal collagen to increase local proliferation while the epidermis is spared, although cooling must ensure superficial protection. PDL (pulsed dye laser) and long-pulsed Nd YAG 1064nm focus on redness, so incidental scar improvement is possible because of decreasing vascularity and its associated secondary effects in the local field or other cellular alterations, specifically about collagen. Most redness associated with striae rubra is resolvable with PDL or other vascular lasers. Nonablative tissue tightening, the epidermal injury is minimized, and thermal energy is directed into the reticular dermis and subcutis, where immediate tissue contraction and delayed remodeling are believed to cause skin tightening collectively. The attractive features of nonablative skin tightening are limited post-procedure healing time, ability to return to work or social engagements, reduced risk of adverse events compared with ablative resurfacing or lifts procedures, and less need for physician oversight. More patients are appropriate candidates for nonablative skin rejuvenation for all these reasons than for ablative or surgical skin tightening.

Nonablative Lasers

Newer rejuvenating laser systems are introduced to stimulate collagen production and remodeling with little or no healing time and minor patient discomfort. The prototype of nonablative rejuvenation lasers is the infrared Nd: YAG laser at 1320 nm (Cool Touch), the diode laser at 1450nm (Smooth beam), and the erbium: glass laser at 1540nm.  They are more effectively targeting the mid dermis, resulting in more consistent mild improvement in rhytides. Photo-thermal and other effects result in collagen contraction. These lasers have minimal melanin absorption spectrum and deep papillary and mid reticular dermal where collagen tightening and new collagen formation are achieved.  It says that outcomes are often gradual, with increased dermal collagen seen in 6 months after four successive treatments, and continued improvement occurs several months after the session. These lasers use conducted heat from the chromophore to produce a diffuse dermal injury, heating to >50°C and inducing collagen remodeling. For stretch marks treatment, Prof Moawad adopts a combination of long-pulsed Nd YAG 1064nm Nd YAG and 1320nm Nd YAG. The nonablative fractional laser systems include; Fraxel restore 1550nm, Fraxel refines 1410nm, Affirm 1440nm, StarLux 1540, Matisse 1540 Dermablate 1540nm, Mosaic 1550nm, and Sellas 1550nm.  Nona-Blative devices produce minimal patient discomfort. Some patients may need a topical anesthetic before the procedure and/or forced cold air cooling during the process. After treatment most, patients notice redness and some edema, which can last for up to 48 hours following the procedure, followed by skin flaking for several more days. With all nonablative fractional devices, there is usually a need for multiple treatments to achieve the result. Most contend that 4 to 6 treatments must attain the given desired outcome for most clinical indications. These lasers, in combination, showed improvement in stretch marks. Nonablative fractional lasers showed mild to moderate acne scarring, pigmentation, white scars, fine wrinkling, and texture changes associated with photoaging on the face, chest, neck, and hands.

Nonablative Light Therapy (Intense Pulsed Light)

The subsequent few therapies are not accurate lasers but rely more on different energy forms to achieve their effect.  The first is intense pulsed light (IPL). These machines emit a wide range of wavelengths from their source that can be precisely narrowed using wavelength filters. Other parameters, such as pulse length, pulse delay, and joules, can also be adjusted. All these options, in combination, allow for tailoring therapy to a defined goal. “IPL offers a therapeutic alternative to the gold standard PDL [for the treatment of hypertrophic scars. The Ellipse IPL treatment directs well-controlled pulses of light into the upper skin layer. This works by attacking the vascularization of the injury. A typical regimen includes up to four treatments spaced four weeks apart. This approach not only reduces the redness of the scar but also stimulates collagen reorganization, thus reducing its size. Intense pulsed light has demonstrated positive results with the reduction of redness and discoloration of STRETCH MARKS,

Ultraviolet Light

UVA and UVB light sources for treatment of STRETCH MARKS showed moderate re-pigmentation in white stretch marks. However, improvement is temporary that needs maintenance sessions.

Radiofrequency Devices

Radiofrequency (RF) devices heat water in tissue and result in collagen remodeling. Radiofrequency devices utilize electrical energy to transfer heat energy to the dermis at relatively low temperatures. These devices are intended to resurface the skin but induce thermal damage to dermal collagen while sparing the epidermis. Resistance and the resultant degree of thermal damage are determined by the depth and composition of the treated tissue. When applied over a period, thermal energy contracts and thickens collagen fibers disrupts hydrogen bonds and alters the conformation of the collagen triple helix.

Furthermore, activation of cellular signaling cascades stimulates fibroblast neocollagenesis. It also induces a more prolonged wound-healing effect associated with sustained remodeling, reorientation, and formation of new collagen bundles over the following months, resulting in effective skin tightening with minimal recovery time. The collagen-based fibrous septa that separate fat lobules in the subcutaneous tissue are also preferentially heated, leading to further collagen denaturation and contraction of the subcutaneous tissue and accounting for the immediate tightening and lifting effect on the skin.

Because RF energy uses an electrical current rather than a light source, it does not affect epidermal melanin; therefore, patients of all skin types, including darker skin types and those with a predisposition to developing post-inflammatory skin pigmentation, may be treated with RF. Everybody is the right candidate for RF, but it is of particular significance to those who do not like invasive surgical intervention and are still young for surgery. Contraindications include implantable medical devices such as pacemakers and defibrillators and current dermatologic conditions like collagen vascular disease and autoimmune diseases. Monopolar systems deliver current using one electrode that contacts the skin and another that acts as a grounding pad. The electrode contacting the surface provides the electric current to the skin. The epidermis is spared by applying a cooling while the dermis is heated uniformly and volumetrically. Aside from rhytides reduction, successful treatment of moderate to severe cystic acne, acne scarring, and cellulite have been reported. The use of more effective, faster tips, lower energy levels, and multiple passes has diminished associated pain but not eliminated it. The low-level multiple passes approach necessitates 4-6 sessions every one to two weeks. The procedure can be repeated everyone year as needed to maintain the results.

Monopolar RF and pulsed dye laser (PDL) combination treatment showed modest results with a reduction in STRETCH MARKS width at 12-week follow-up. The main difference between bipolar and monopolar RADIOFREQUENCY is the configuration. The monopolar RADIOFREQUENCY devices have one active electrode placed on the skin and a grounding electrode. The bipolar configuration consists of two active electrodes set a short distance apart, overlying the intended treatment area. The current flows between the two electrodes. The depth of penetration is half the distance between the two electrodes. The significant limitation of the bipolar RADIOFREQUENCY devices is the depth of penetration. The mechanism of action for simple bipolar RADIOFREQUENCY devices is like that of the monopolar RADIOFREQUENCY device.  A combination of light devices has been used to overcome this limitation. Bipolar RADIOFREQUENCY devices are often combined with light-based technologies, termed electro-optical synergy (ELOS). The ELOS system uses the synergistic effects of light and RADIOFREQUENCY-based devices. The light energy preheats the target tissue through photothermolysis, which lowers the tissue’s impedance. The lower impedance makes the tissue more susceptible to the RADIOFREQUENCY part so that it is selectively targeted. Therefore, lower levels of energy of the light and RADIOFREQUENCY part are needed to produce the desired effect with fewer side effects. The optical component also targets fibroblasts, blood vessels, and dyschromia. The volume of treated tissue is limited to that found between the electrodes in the special vacuum tip, so lower energy levels can be used to meet the energy density needed to reach and affect the chosen skin layers, leading to greater efficacy, less pain, and lower incidence of side effects.

Fractional Radiofrequency (FRF)

Fractional RADIOFREQUENCY is a newer nonablative approach. There are two ways to deliver fractional RADIOFREQUENCY. Whereas some devices (Matrix RADIOFREQUENCY device) use electrodes, others use an array of micro-needles arranged in pairs between which bipolar RADIOFREQUENCY energy is delivered (ePrime system).  The fractionally distributed energy creates zones of affected skin adjacent to unaffected areas. The treated areas have thermal damage in the deep dermal collagen, stimulating wound healing, dermal remodeling, new collagen, elastin, and hyaluronic acid formation. The unaffected areas located in between affected areas initially maintain skin integrity but, in the long term, serve as a reservoir of cells that promote and accelerate wound healing. Microneedle fractional RADIOFREQUENCY also improved acne scars and large facial pores with fewer adverse events than fractional lasers. However, moderate to severe acne scars showing superficial irregularities require multiple microneedles fractional RADIOFREQUENCY treatment sessions for functional improvement. A new device has been developed that combines fractionated optical energy with a 915-nm diode coupled with a fractionated bipolar RADIOFREQUENCY. This integrated system targets the epidermis and superficial l dermis. By using the RADIOFREQUENCY component synergistic, less energy is used to heat the collagen in the deep dermis and stimulate new collagen formation and contraction (Matrix eLaser). This device has been associated with significant improvement in acne scarring, texture, and pigmentation. It appears that FRADIOFREQUENCY devices are a safe, tolerable, and effective modality for wrinkles and facial laxity reduction. The most common side effects are erythema and edema, which are transient, and patient discomfort does not seem to be a significant disadvantage. I may use a topical anesthetic cream before the treatment to minimize pain.

Ablative Laser Skin Rejuvenation (Resurfacing)

Ablative CO2 Laser

During the late 1990s and early 2000s, the gold standard for the treatment of facial lines and wrinkles as well as acne and traumatic scars was, at least from a laser point of view, the carbon dioxide (CO2) laser system. Carbon dioxide laser was first utilized for post-acne scarring, commonly replacing dermabrasion and intense chemical peeling. The CO2 laser emits a 10.600nm wavelength, which is strongly absorbed by tissue water. The penetration depth is dependent upon water content and independent of either melanin or hemoglobulin. This treatment is more aggressive and more profound than a chemical peel but remains at 20 to 30 um specific depths with thermal damage of 50 to 150 um. It is usually bloodless but still achieves total ablation of the epidermis and a portion of the dermis. In addition to the destructive nature, there may also be stimulation of collagen by the procedure. The usefulness is primarily for hypertrophic scars, boxcar scars (preferably shallow), and, less effectively, keloids. Some achieve quick results, visible as soon as two weeks, but improvement because of the wound-healing phases continues for at least 18 months.

Ablative CO2 laser treatment of stretch marks proved a promising clinical improvement in randomized trials and observational studies. Downtime with the CO2 laser typically lasted about one week or more. Depending on the device and the aggressiveness of the clinician utilizing the equipment, potential adverse effects became more widespread. Although traditional ablative laser resurfacing was able to achieve results for skin tightening, which rivaled surgical correction, the possible adverse effects included pain, edema, persistent erythema, infections, post-inflammatory hyper-pigmentation, and the most problematic of all, hypopigmentation following the ablative procedure, seen in some patients two years following the laser surgery significantly limited the application of this technology. Future researchers to develop laser settings that maximize positive outcomes while minimizing the risk of PIH are needed.

Ablative Erbium YAG Laser

To counter these potential adverse events, the Er: YAG laser was introduced. It emits a wavelength of 2940 nm in the infrared range, which is close to the absorption peak of water and yields an absorption coefficient 16 times that of the CO2 laser.  This provides a more precise ablation of skin with minimal thermal damage to the surrounding tissue minimal thermal damage to the surrounding tissues, resulting in less severe side effects and faster overall healing times. Downtime still may be from 5 to 7 days, depending on the power utilized. Er: YAG lasers can even occur and other problems similar to those of the CO2 laser. Again, this may be of benefit for hypertrophic scars, rarely keloids, and shallower boxcar scars.

Ablative Plasma Skin Resurfacing

Plasma skin resurfacing. A device for performing ablative resurfacing has been developed, which works by passing radiofrequency into nitrogen gas. The “nitrogen plasma” causes rapid skin heating with limited tissue ablation and minimal collateral thermal damage. Results appear to be similar to gentle CO2 and Er: YAG laser resurfacing. The more aggressive the treatment, the higher the fluence, the more impressive the results. Laser skin resurfacing has been employed to treat many skin conditions, but photoaging and scarring are the two most common indications.

Fractional Laser Skin Peel 

The field of skin resurfacing has evolved rapidly over the past two decades from ablative lasers including CO2 and Er: YAG to nonablative systems employing near IR lasers, IPL, RF, and ultrasound to Fractional photothermolysis (FP) or thermolysis (FT).  FT was developed for laser surgeons to get closer to ablative laser resurfacing clinical outcomes with less patient downtime and fewer overall adverse events.  Stated, FT is the production of an injury pattern to the skin with skip areas repeated, which, as they heal, promote an improvement in the tone and texture of the skin, in lines and wrinkles, in pigmentary concerns including melasma and scars, especially acne and traumatic scars. The concept of fractional emission of light into microscopic zones of injury contrasts with traditional ablative skin resurfacing using a CO2 or erbium laser. A flat beam induces a confluent, uniform patch of epidermal or dermal damage. After a 48- to 72-hour re-epithelialization and repair starts mediated by the adjacent columns of intact tissue. In this 30-day phase, the areas of thermally ablated tissue are repopulated by fibroblast-derived neocollagenesis and epidermal stem cell reproduction.

In more technical terms, small columns of thermal injury to the skin are known as microthermal zones (MTZs). These MTZs vary from device to device. Some are nonablative dermal injuries only; while, others are associated with ablative changes in the skin, causing both epidermal and dermal injury patterns. MTZs also vary in their effect diameter and the degree of depth they achieve to create the injury. Once injured, the skin begins a very rapid process of repair. The repair mechanisms seen in FT occur through the trans-epidermal delivery of treated necrotic skin into the stratum corneum, in which it is exfoliated away in a short time. This process is known as microscopic epidermal necrotic debris (MENDs). MENDs is another term routinely associated with FT and appears unique to FT. The rapid healing process is made possible through the help of the surrounding “normal” or untreated skin—another process unique to FT.

Based upon these mechanisms of action, nonablative FP holds great promise in both treatments of skin textural abnormalities (acne scarring, rhytides, and skin mottling associated with photoaging) as well as pigmentary variation (melasma, hyperpigmented scars, lentigines, and dyschromia). One of the significant advantages of nonablative FP is the low incidence of adverse side effects. Fractional thermolysis (FT) can be divided into several classifications. The easiest has been to classify FT devices into nonablative and ablative FT laser systems. This classification was “easy” at the beginning when only several tools were available. It is now a little more complicated, especially among the ablative laser systems. Thus new terminology seems prudent currently. Ablative FT laser systems originally were divided into classifications based on laser type: CO2, Er: YAG, or YSGG, 2790nm. What has changed is that different ablative FT laser systems emit light differently, with penetration depths that may be considered “superficial” and others that it may regard as “deep.” Thus, a new classification system seems prudent at this point. Ablative FT lasers have been classified into “micro-ablative FT laser systems,” which would include those lasers that produce epidermal and dermal damage to a depth less than 750 microns, and “deep dermal ablative FT laser systems,” which would consist of those lasers that produce damage beyond 750 microns in the skin.

Platelet Rich Plasma (PRP)

Platelet-rich plasma (PRP) is used to improve the healing of ablative fractional resurfacing wounds. Autologous Platelet Rich Plasma uses platelets prepared from the patient’s blood to support and accelerate hard and soft tissue regeneration. As vehicles for controlled delivery of growth factors, platelets are injected into the dermis, where they induce proliferation of fibroblasts, promote the production of new collagen and other extracellular matrix components, stimulate stem cell migration proliferation and differentiation, and improve micro-vascularization.

professor-moawad

Stretch marks prevention and treatment stay a clinical challenge as proof by the multitude of methods to prevent and treat STRETCH MARKS. Lack of a single modality or regimen that results in cure limits recommending a pattern alone. Physicians should set realistic expectations with patients seeking STRETCH MARKS treatment. Informing patients that the appearance and texture of STRETCH MARKS may improve but will not completely resolve is an integral part of setting these expectations. Topical treatment with silicone, retinoids, and hyaluronic acids has shown some improvement in STRETCH MARKS. For the treatment of RED STRETCH MARKS, clinicians may consider the PDL, 1,064-nm Nd: YAG laser, and 532-nm KTP laser, which would likely improve the redness (vascular component) of RED STRETCH MARKS.

Recently, several emerging treatment modalities, including fractionated micro-needling RF, ultrasound, and PRP and micro-needling, have been published. These treatment modalities reported good clinical improvement of stretch marks. Nonablative and ablative fractionated lasers can become a promising modality for treating STRETCH MARKS with clinical striae improvement. Currently, no one treatment modality can significantly improve STRETCH MARKS. We encourage clinicians to consider utilizing a combination treatment approach with topicals and lasers, instead of a single treatment modality, for the treatment of STRETCH MARKS.

Some women are simply trying to accept the new skin now that the baby has arrived. “Knowing that there’s no magic spell, I have decided to embrace [the stretch marks] as a part of my new mom body. New curves, new shape — new skin, too,” a new mom says.

Call Now
[contact-form-7 id="6" title="Contact form 1"]
[layerslider id=”81″ /]