CO2 Laser for Stretch Marks

Guilherme Almeida, Elaine Marques, and Rachel Golovaty

Abstract Keywords
Stretch marks or striae distensae (SD) are a Stretch marks • Striae distensae • Striae rubra •
well-recognized, common dermatologic entity, Striae alba • Striae atrophicans • Striae
which affect patients of all ages, genders, and gravidarum • Laser therapy • Light therapy •
ethnicities and rarely cause any significant Acid peel treatments • Collagen injection •
medical problems but can have a deep psycho- Laser lipolysis • Radiofrequency • Micro-
logical impact on affected patients. Risk fac- dermabrasion • Nonablative lasers • Fractional
tors have been reported, but much remains to laser resurfacing
be understood about their epidemiology.
Although there is no standard treatment for Contents
SD, many topical applications, peeling, light, Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
and laser systems, have been tried. Consider-
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
ing the many modalities used to improve SD,
lasers have recently become a popular thera- Histopathogenesis of Striae Distensae . . . . . . . . . . . . . 173
peutic alternative. The aim of this chapter is to Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
discuss the causes and possible treatments
Lasers and Light Devices . . . . . . . . . . . . . . . . . . . . . . . . . . 174
described in literature, to approach the clinical
efficacy and safety of fractional CO2 laser in Author Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
the treatment of SD, and to show 5 years of our Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
experience using this device. Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Introduction
G. Almeida (*)
Department of Dermatology, Hospital Sirio Libanes, Roederer first described striae in 1773, and Troisier
Brazil – Private office: Clinica Dermatologica Dr
and Menetrier made the first histological descrip-
Guilherme de Almeida, Sao Paulo, Brazil
e-mail: dermaalmeida@uol.com.br tions in 1889 (Troisier and Ménétrier 1889). Striae
distensae (SD), also denominated stretch marks
E. Marques • R. Golovaty
Clinica Dermatologica Dr Guilherme de Almeida, Sao (SM), striae rubra, striae alba, striae atrophicans,
Paulo, Brazil striae gravidarum (SG), are a well-recognized com-
e-mail: elainedermato@gmail.com; mon dermatologic entity, which affect patients of all
rachelaqueiroz@hotmail.com

# Springer International Publishing AG 2018 171

M.C.A. Issa, B. Tamura (eds.), Lasers, Lights and Other Technologies, Clinical Approaches and Procedures in
Cosmetic Dermatology 3, https://doi.org/10.1007/978-3-319-16799-2_12
172 G. Almeida et al.

ages, genders, and ethnicities. SD is common in Elton and Pinkus 1966; Cohen et al. 1997; Mur-
adolescence, pregnancy, and obesity. The most com- phy et al. 1992). Risk factors in pregnant women
monly affected sites are the breasts, upper arms, may be constitutional (maternal age and BMI)
abdomen, buttocks, and thighs. Initially, SD present or pregnancy related (birth weight, gestational
as edematous red or pink linear plaques called striae age, weight gain during pregnancy, and poly-
rubra. Over time, the color fades, and the lesions hydramnios) (Ghasemi et al. 2017; Osman et al.
become hypopigmented, atrophic, and permanent 2017; Atwal et al. 2006; Canpolat et al. 2010;
(striae alba). It is rarely caused by systemic diseases Murphy et al. 1992).
but commonly represents a deep psychological Many risk factors have been suggested for the
impact on affected patients (Al-Himdani et al. development of SG, such as pregnancy maternal
2014; Watson et al. 1998; Ud-Din et al. 2016). weight (Ersoy et al. 2016; Liu 1974; Thailand
SD is a known feature of several clinical con- J-Orh et al. 2008), weight gain during pregnancy
ditions, both chronic and acute, with very distinct (Osman et al. 2017), maternal age (Atwal et al.
pathophysiology (e.g., pregnancy, adolescent 2006), skin structure (Ghasemi et al. 2017), family
growth spurts, obesity, large weight gain, Cushing history (Chang et al. 2014), race, and birth weight
syndrome, Marfan syndrome, diabetes mellitus, (Liu 1974). These have been investigated, but
long-term systemic or topical steroid use), making their effect has not been clearly proven (Davey
it difficult to determine their true etiology. Most 1972; Liu 1974; Thomas and Liston 2014;
SD research has focused on pregnant women and Muzaffar et al. 1998; Kartal Durmazlar and
adolescents. A positive family history is a risk Eskioglu 2009). Surgical interventions and medi-
factor in both of these groups alike. Among ado- cations have also been associated with SD
lescents, BMI and childhood obesity both influ- (Osman et al. 2017; Pinkus et al. 1966; Di Lernia
ence risk of developing SD (Troisier and et al. 2001; McKusick 1971; Rolleston and Goo-
Ménétrier 1889). dall 1931; Shafir and Gur 1999; Tsuji and Sawabe
1993; Gupta 2000).
Ersoy et al. (2016) published a new study to
determine individual risk factors related to SD and
Epidemiology reported some preventive measures. This prospec-
tive observational study included 211 primiparous
The prevalence of SD reported in the literature pregnant women who were hospitalized for birth
varies a lot, ranging from 6% to 88% (Cho et al. and did not have systemic diseases or other risk
2006; Sisson 1954; Kelekci et al. 2011; Thomas factors (drugs use or polyhydramnios). The use of
and Liston 2014; Chang et al. 2014; Ghasemi et al. preventive oil or drugs, smoking status, skin type,
2017; Osman et al. 2017; Davey 1972; Elton and water intake, and level of financial income did not
Pinkus 1966; García-Hidalgo et al. 1999; García- significantly predict the appearance of SG.
Hidalgo 2002). The prevalence ranges from 6% to According to the logistic regression analysis,
86% in adolescents and from 43% to 88% in including all variables found to be significant in
pregnant women (Cho et al. 2006; Chang et al. one-by-one comparisons, i.e., age, pregnancy
2014; Ghasemi et al. 2017; Osman et al. 2017; BMI, BMI at admission, abdominal circumfer-
Atwal et al. 2006; Canpolat et al. 2010; Maia et al. ence, birth weight, family history, sex of the
2009; Jaramillo-Garcia et al. 2009; Cohen et al. infant, and maternal education level, it was
1997). Among obese individuals with a BMI of established that each unit of decrease in maternal
27–51, the prevalence is reported to be 43% age increased the risk of SG by 1.15-fold
(García-Hidalgo et al. 1999). The prevalence (Ghasemi et al. 2017; Muzaffar et al. 1998; Kartal
among nonpregnant women and adult male Durmazlar and Eskioglu 2009; Thomas and
varies a lot in literature (Kelekci et al. 2011; Liston 2014).
CO2 Laser for Stretch Marks 173

Histopathogenesis of Striae Distensae stage are classified as “striae alba” (SA) and are
considered permanent (Watson et al. 1998;
Three main theories relating to SD formation are Ackerman Ab et al. 1997; Arem and Kischer 1980).
described: mechanical stretching of the skin, hor- Striae distensae can be considered a form of
monal changes, and an innate structural distur- dermal scaring, and their clinical and histological
bance of the tegument. Mechanical stretching of are similar to those of scar remodeling. For what-
the skin is postulated due to the perpendicularity ever reason, dermal collagen ruptures or separates,
of SD to the direction of the skin. However, and the resulting gap is replaced with newly formed
contradictory studies dispute this theory collagen that orients itself in the direction of local
(McKusick 1971; Nigam 1989). Adrenocortico- stress forces (Sisson 1954). Irrespective of the
trophic hormone (ACTH) and cortisol are underlying pathology that may incite a cascade of
thought to promote fibroblast activity, leading uncertain events, a final common pathway results
to increased protein catabolism, modifying col- in the breakdown and tearing of the dermal matrix,
lagen and elastin fibers (Klehr 1979). Pregnancy- which manifests clinically as SD.
related hormones are also believed to influence A recent study investigates early molecular
SD formation (Osman et al. 2017; Nigam et al. alterations that may promote laxity of mature
1990; Cordeiro et al. 2010; Lurie et al. 2011). striae gravidarum (SG). They investigated the
Disorder of extracellular matrix’s gene expres- dermal elastic fibers network, which provides
sion is also postulated as a possible mechanism elastic properties of the human skin. They
involved in SD formation (Etoh et al. 2013; obtained skin samples of newly developed, ery-
Friedman et al. 1993). thematous abdominal SG in healthy pregnant
The exact pathogenesis of striae is still contro- women. Elastic fibers were examined by Verhoeff
versial. Early histological dermal alterations may stain and immunofluorescence. The normal elastic
be visualized on electron microscopy including fiber network appeared markedly disrupted in SG,
mast cell degranulation and macrophage activa- compared with perilesional abdominal skin or
tion leading to elastolysis of the mid-dermis. control (normal-appearing hip skin). This disrup-
Release of enzymes by mast cell, including elas- tion was accompanied by the emergence of short,
tases, is proposed as a key initiatory process in SD disorganized, thin, threadlike “fibrils,” which
pathogenesis. The inflammatory process induces were observed prominently in the mid-to-deep
collagen, elastin, and fibrillin modifications. The dermis. These fibrils were rich in tropoelastin
reorganization of fibrillin and elastin are thought (the main component of normal elastic fibers)
to play an important role in SD pathogenesis, and and persisted into the postpartum period without
those who are predisposed to developing SD may forming normal-appearing elastic fibers. The
have an underlying deficiency of fibrillin (Watson emergence of these fibrils was accompanied by
et al. 1998; Sheu et al. 1991). increased gene expression of tropoelastin and
A deep and superficial perivascular lympho- fibrillin-1 but not other elastic fiber components
cytic infiltrate with occasional eosinophils and such as fibrillin-2 and fibulin-1, fibulin-2, and
dilated vessels with edema of the upper dermis fibulin-5. They concluded that in early SG, the
are characteristic of newly acquired striae. SD in elastic fiber network appears markedly disrupted
this stage is referred to as “striae rubra” (SR). and newly synthesized tropoelastin-rich fibrils
In late stage, elongated collagen bands are con- emerge as an uncoordinated synthesis of elastic
centrated within the upper third of the reticular der- fiber. Because they are thin and disorganized,
mis and arranged parallel to the surface of the skin. tropoelastin-rich fibrils do not function as normal
In the “terminal” stages of SD, there is a thinning of elastic fibers. These findings help to elucidate the
the epidermis due to blunting of the rate ridges and a pathogenic mechanism by which laxity occur in
paucity of collagen and elastic fibers. SD in this SG (Wang et al. 2015).
174 G. Almeida et al.

Treatment of evidence for each topical formulation. The

majority of topical products failed to mention
Striae distensae is a considerable challenge in their effect on early SD vs. later stages of SD
terms of their treatment. They rarely resolve (striae rubrae compared to striae albae) and their
without intervention. Even with intervention, role in both prevention and treatment. In conclu-
improvement rather than complete resolution is a sion, there is no topical formulation that is shown
more realistic goal. The best results are achieved to be most effective in eradicating or improving
when treating SD in the early phase. Once SD SD. A structured approach in identification and
reaches a mature, static phase, they are signifi- targeted management of symptoms and signs
cantly more resistant to treatment. with the appropriate topical is required. Random-
Various treatment modalities are reported ized controlled trials are necessary to assess the
to treat or prevent SD. Among them are laser efficacy of topical products for treatment and
therapy (Cho et al. 2006; Belo and Arceo-Cruz prevention of different stages of SD (Ud-Din
2009; Alexiades-Armenakas et al. 2011), light et al. 2016).
therapy (Sadick et al. 2007), chemical peelings
(Mazzarello and Farace 2012), percutaneous
collagen induction (Aust et al. 2010), laser lipol-
ysis (Freedman 2010), radiofrequency techniques Lasers and Light Devices
(Suh et al. 2007), and microdermabrasion (Abdel-
Latif and Albendary 2008). No single therapy The 585 nm flash lamp-pulsed dye laser (PDL) at
has been advocated to completely eradicate low energy densities is commonly used to
these lesions (see also the following chapters: target the dilated blood vessels of striae rubra.
▶ “Non-ablative Lasers for Stretch Marks,” this An increase in the amount of collagen has been
volume; ▶ “Transepidermal Drug Delivery with reported after a series of PDL treatment
Ablative Methods (Lasers and Radiofrequency),” (McDaniel et al. 1996; Alster 1997). The PDL
this volume). has a moderate, beneficial effect in reducing the
Even when procedures are indicated, topical degree of erythema in striae rubra but no apparent
treatment is considered the most used treatment benefit in striae alba. Because of the potential for
and can be used before or associated with pro- adverse effects, PDL should be performed with
cedures (Kelekci et al. 2011). A recent article extreme caution in patients with Fitzpatrick V-VI
assessed the evidence for the use of topical treat- skin type. McDaniel et al. undertook a controlled
ments for SD. They reviewed the published liter- of 39 patients with SD. Treatment sites included
ature in English language, from 1980 onward the abdomen, thighs, and breasts. Four treatment
(Kelekci et al. 2011). The products were catego- protocols were used with different spot distances
rized by their mechanisms of action, including and fluences. Untreated SD was the control. Out-
those which acts in stimulating collagen produc- comes were measured by subjective analysis,
tion, increasing elasticity, and improving cell shadow profilometry, and histological analysis.
proliferation and those with anti-inflammatory A significant reduction in skin shadowing was
and rehydration properties. The results showed reported in patients with SD in all proto-
that there are few studies (n = 11) that investigate cols compared to controls. Additionally, elastin
the efficacy of topical in management of regained its normal appearance in SD treated
SD. Trofolastin and Alphastria creams demon- with low-fluence PDL (McDaniel et al. 1996;
strated level 2 evidence of positive results for Hernández-Pérez et al. 2002).
their prophylactic use in SD. Additionally, tretin- Intense pulsed light (IPL), characterized by a
oin used therapeutically showed varied results, noncoherent filtered flash lamp with a broadband
while cocoa butter and olive oil did not demon- spectrum (515–1200 nm), has been shown to
strate any effect. Overall, there was a distinct lack replace dermal elastosis with neocollagen, thus
CO2 Laser for Stretch Marks 175

improving the appearance of mature SD after a dark skin (Alster and Lupton 2002; Lee et al.
series of treatments (Zelickson et al. 2004). 2010). Fractional photothermolysis (FP) was
Radiofrequency (RF) devices produce heat developed to overcome adverse effects
which converts electrical current to thermal associated with traditional ablative laser
energy that is uniformly dispersed to different resurfacing and low efficacy of nonablative lasers
tissue depths. It increases collagen production by (Lee et al. 2010; Geronemus 2006).
inducing collagen type I mRNA expression Fractional laser resurfacing can be delivered in
(Manuskiatti et al. 2009). either an ablative or nonablative mode. These laser
The long-pulse 1064 Nd:YAG is a nonablative devices generate focused laser energy that is deliv-
treatment for facial wrinkles, and an increase in ered in a microarray pattern, producing small col-
dermal collagen has been reported after treatment. umns of tissue destruction in the epidermis and
It also has a strong affinity to vascular targets, mak- dermis, termed microscopic treatment zones
ing it a useful modality in the treatment of SR. The (MTZs), with intervening islands of healthy tissue.
1064 Nd:YAG laser can be safely used, even in Within these cones of destruction, the induction of
patients with dark skin types (Goldman et al. 2008). tissue remodeling and synthesis of new collagen
The 308-nm xenon-chloride excimer laser (XeCl) and elastic fibers occurs. The surrounding unaf-
used in psoriasis, vitiligo, and post-inflammatory fected, healthy tissue serves as structural scaffolding
hypopigmentation has been used to repigment as well as provides nutritional support for the treated
SD. Posttreatment biopsies showed increased mela- zones, offering the advantage of significantly
nin pigment, hypertrophy, and increased number of reduced healing times (Fisher and Geronemus
melanocytes; however, they failed to demonstrate 2005). The difference between ablative and non-
any improvement in skin atrophy (Goldberg et al. ablative FP lies in the variable degree of vaporiza-
2003, 2005). Alexiades-Armenakas et al. conducted tion of columns of tissue (ablative) versus thermal
a randomized-controlled trial of 31 patients with injury with residual epidermal necrotic debris (non-
SD. Lesions were randomized by alternate allocation ablative). The nonablative technique achieves only
to receive treatment or not. Treatments were minimal efficacy and requires multiple treatment
performed at biweekly intervals until a maximum sessions over an extended period of time, while
of ten treatments were undertaken; 75% increase in the fractional ablative technique boasts superior
colorimetric measurements relative to baseline or efficacy, however, with more discomfort, postoper-
100% visual pigment correction was obtained. Out- ative erythema, and recovery time (Suh et al. 2007).
come measures included visually assessed pigment Fractional laser resurfacing devices demonstrate
correction relative to control assessed by three superior efficacy over other modalities of treatment
blinded observers and skin pigmentation levels mea- techniques for photorejuvenation and have proven
sured on a colorimeter. A statistically significant particularly effectiveness for acne scars, deep facial
improvement in pigmentation was identified in rhytides and atrophic scarring. Given the clinical
treated SD vs. site-matched controls. Improved and histologic similarity of striae to the dermal
visual pigmentation levels compared to controls scarring characteristic of these conditions, compa-
were also reported, but this declined toward baseline rable outcomes could theoretically be achieved in
after 6 months. Alternate allocations in this study SD. The fractional ablative 10,600 nm carbon
were blinded to treatment. Attrition bias may be dioxide CO2 laser has been shown to be highly
another concern as there is no report of how many efficacious for skin resurfacing as well as for the
patients were in the final analysis (Alexiades- treatment of atrophic scars due to its ability to
Armenakas et al. 2004). stimulate collagen and elastin regeneration and
Ablative lasers, as short pulse 10,600 nm CO2 remodeling. Additionally, it has been documented
laser, trigger epidermal vaporization and coagula- that the fractional CO2 laser induces neocollagensis
tion of the underlying dermis. They present a risk to a greater degree than the nonablative lasers
of hyperpigmentation, particularly in those with (Rahman et al. 2009).
176 G. Almeida et al.

Due to the high risk of pigmentary alteration in Deep Fx) in the last 5 years. During this period,
ethnic skin, the use of the CO2 laser in patients we have documented treatment of 500 Brazilian
with phototypes IV–VI has largely been discour- patients (Fitzpatrick skin types III to V) with SD
aged; however, when used with appropriate cau- who were followed up for 2 years.
tion, it appears that the fractionated CO2 systems For the treatment, topical lidocaina associ-
are safe and efficacious for the treatment of SD ated with tetracaina cream was applied on the
with no appreciable increase in risk for PIH. skin 20–60 min before laser therapy. Treatment
Combination therapy may be the future for consists of applying two passes of laser. The first
treating SD. Multiple simultaneous approaches pass was performed over the SD using a linear
may afford the use of lower fluences, ultimately pattern, energy of 5–20 mJ, density 5–15%, with
decreasing adverse effects. Strict adherence to single pulses. The second pass was performed
laser parameters and standardization of photogra- using a square pattern, energy of 2.5–10 mJ,
phy will be essential to ensure valid results. While densities 5–15%, with single pulses. This sec-
a variety of energy devices could theoretically be ond pass was performed not only over the SD but
used in combination, only a handful of well- also around the SD. Patients were advised to
powered studies have been performed, so it is kindly wash the area, to apply a healing cream
hard to say which combination will be at the twice a day for 2 weeks, and to avoid sun expo-
forefront (Aldahan et al. 2016). sure for 3 weeks. After this period, they were
oriented to wear chemical and physical topical
sunscreen.
Clinical results were evaluated 3 months and
Author Experience 2 years after treatment, through image software,
which quantifies SD volume before and after treat-
In our daily practice, both striae rubra and striae ment through an overlap of before and after images.
alba, located in different areas of the body, have Three months after treatment, 100% of patient
been treated with CO2 fractional laser (Ultrapulse, had improved. Among them, 15% was considered

Fig. 1 Before and 24 months after treatment: excellent improvement

CO2 Laser for Stretch Marks 177

Fig. 2 Before and 24 months after treatment: excellent improvement

Fig. 3 Before and 24 months after treatment: good improvement

excellent improvement, 65% good improvement, have good results was the abdomen and then the
and 20% moderate improvement. These results thighs.
were sustained during 2 years of follow-up Degree of patients satisfaction was considered
(Figs. 1, 2, 3, 4, and 5). excellent in 10% and great in 90%.
Best results were achieved for striae rubra, Post-inflammatory hyperchromia was a transi-
compared with striae alba, and for SD located on tory side effect. To avoid dyschromia, we advo-
the breast. The second best anatomy region to cate the use of low densities.
178 G. Almeida et al.

Fig. 4 Before and 24 months after treatment: excellent improvement

Fig. 5 Before and 24 months after treatment: good improvement

Conclusion Take Home Messages

Striae distensae are a well-recognized, common • Striae distensae commonly occur in pregnancy,
dermatologic entity, which affect patients of all puberty, and obesity.
ages, genders, and ethnicities and rarely cause • Proposed etiological mechanisms are hor-
any significant medical problems but can have a mones, physical stretch, and structural alter-
deep psychological impact on affected patients. ations to the tegument.
Many treatment modalities are available for • Striae distensae does not have one standard treat-
treatment and prevention; however, striae ment but many different treatment modalities.
distensae is still a challenge for dermatology. • Treatments include topical agents, radio-
Laser treatment can be a good option when frequency, percutaneous collagen induction,
performed by experts. Fractional CO2 laser can microneedling, IPL, and nonablative and abla-
bring very good results, but appropriated param- tive lasers.
eters must be adjusted according to the device. • Expectations must be realistic, but the frac-
Low density is an important parameter to avoid tional CO2 laser has recently shown improve-
side effects. ment of these aesthetically distressing lesions.
CO2 Laser for Stretch Marks 179

• Best results were achieved for striae rubra, primipara pregnants. Turkderm Deri Hastaliklari ve
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