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Stretch Marks

Stretch marks are often mistakenly blamed on the rapid stretching of the skin associated with such life events as pregnancy and growth spurts, but in actuality this is untrue. Stretch marks (also referred to as striae distensae) are the result of an increased level of circulating glucocorticoids throughout the bloodstream. This hormone, secreted by the adrenal glands (they lie on top of the kidneys), becomes elevated during pregnancy, adolescence, with obesity, weight lifting and Cushing's disease.

Medications such as oral steroids can also cause stretch marks to develop. Stretch marks can even form from chronic over use of low potency topical steroid creams and ointments driven more deeply into the skin when covered with such materials as plastic wrap. High potency topical steroids require no occlusion to wreak havoc upon the skin and result in striae.

A Lack Of Support

All the stretching in the world will not result in a stretch mark so long as there is support within the dermis. Stretching may determine where the stretch marks will appear and also plays a role in which direction they run. But stretching alone is not the cause of a stretch mark. Perhaps the term stretch mark is really a misnomer!

Those glucocorticoids responsible for the development of a stretch marks affect the dermis by preventing the fibroblasts from forming collagen and elastin fibers, necessary to keep rapidly growing skin taut. This creates a lack of supportive material, as the skin is stretched and leads to dermal tearing. The epidermal cells are also affected, so the epidermis becomes thin and flattened, allowing for more visibility of the defects below.

If you were to look at a stretch mark under the microscope, you'd see that the dermis is thinner than normal. The collagen fibers have been pulled apart from each other, and the elastic fibers are broken and lie clumped along the edges of the stretch mark. They are nowhere to be found within the heart of the tear. Remember a healthy dermis is literally a chain linked fence, preventing sagging and crepiness seen later in life with wrinkles. If tears develop, the skin will show it.

As the stretch mark ages and turns white, this is the regeneration phase. The collagen bundles mix with some abnormally thin elastic fibers but are unable to fully realign themselves in a proper manner. The elastic fibers continue to be absent deeper in the dermis. Treatment is aimed at trying to normalize this cutaneous disarray.

Red, White and Blue?

If you're blue about having stretch marks, you aren't alone. However, there is a lot of information that has come through the medical journals recently on the treatment and prevention of stretch marks. Your chances of improving the look of your stretch marks will be higher if you understand that therapy will be based upon what your stretch marks look like (basically the phase of development) and make the appropriate treatment selection.

Stretch marks are most commonly seen in such areas as the abdomen, buttocks, hips, breasts and thighs. Wrinkled, crinkled strips of skin develop a red and often raised appearance early in the life cycle of a stretch mark. If your skin is dark, you may not necessarily see a red tone to the skin but it's there. Over time stretch marks turn to a dusky purple and finally into flattened white bands. Everyone is acquainted with their appearance but most are fully unaware of how to cause their disappearance. Treatment varies by the specific phase of the stretch mark.

Stop Sign Red

Medically known as striae rubra. Here lies your best chance of really making an impact upon the ultimate demise of your stretch marks. Your options include:

  • Mederma applied 3-4 times daily for an estimated 6-12 months.
  • Cellex-C High Potency Serum applied daily for 6-12 months.
  • Prescription 0.1% Tretinoin (Retin A 0.1% Cream or Gel) applied nightly (start out every other night until your skin has become adjusted) for 12 months. A non-prescription options include Afirm 3X & DERMAdoctor Poetry In Lotion intensive retinol 1.0. These options are not appropriate if you are pregnant or nursing. Wait until afterwards to try it.
  • Treatment with a 585-nm pulsed dye laser. This is not recommended for anyone with a dark skin tone (Fitzpatrick Skin Type IV, V or VI) due to a high risk of permanent increased skin discoloration from the procedure. This is another option to skip while pregnant or nursing.

The idea behind treating anything early on is that you are limiting the amount of damage that is caused. Cellex-C has already been documented to help stimulate fibroblasts to produce collagen and elastin fibers. These are essential in helping prevent the formation of stretch marks. And while Mederma has shown good results in helping treat red, raised stretch marks, we still do not really understand why. It is safe to use while pregnant and nursing and certainly as "natural" as one can get. The active ingredient is nothing but onion juice extract.

Tretinoin has long been suspected of stimulating fibroblast activity resulting in the formation of collagen and elastin fibers. In addition, exfoliation will occur helping create a more uniform surface.

White Out

Medically called striae distensae alba. Let's be honest; most of you reading this article are far past adolescent growth spurts and may even be looking at what seems like ancient post partum concerns. But there are wonderful opportunities to take an aggressive approach to your stretch marks and try to greatly improve their appearance.

I have received many a hopeless letter from those with older white stretch marks who have been told by their doctor "you needed to do something when they were red, there's nothing you can do now". First corollary of medicine: never give up. The good news is you don't have to.

Here are your options:

The Department of General Surgery at Portsmouth's Naval Medical Center published a great study in 1998 in the Journal of Dermatologic Surgery looking at how best to handle white stretch marks. Specifically they looked at what would happen if they had a group of women with white stretch marks apply Priori Advanced AHA Hand & Body Revitalizing Lotion once daily and either include Cellex-C High Potency Serum or 0.05% tretinoin (Renova 0.05% Cream) at another time of day. They found that over the course of 12 weeks, there was definite improvement with either regimen.

Subtleties in the study results included that the Priori Advanced AHA Hand & Body Revitalizing Lotion/Renova group, had already formed 20% more elastin fibers. Also, microscopic proof was found that both groups increased the thickness of the epidermis and papillary dermis within the stretch mark approaching that of normal skin.

Unbuffered, glycolic acid at a concentration of 20% can be highly irritating to the skin. The choice of Priori Advanced AHA Hand & Body Revitalizing Lotion or Nutraderm Advanced Formula Lotion were ideal as they both offer therapeutic effectiveness with a minimum of irritation.

Renova is a prescription item, and if you are unable to obtain this from your doctor, you can try substituting a potent retinol such as DERMAdoctor Poetry In Lotion intensive retinol 1.0. Starting any topical Vitamin A cream is tricky if you wish to avoid potential irritation. Start out every other night using just a pea-sized amount to each treatment area (a pea-size per hip for instance). Make certain that the skin is dry (wait 30 minutes after washing) before application. Also, avoid using this product if you are pregnant or nursing; go with Cellex-C High Potency Serum instead. Both glycolic acid and Vitamin A creams can cause an increase in photosensitivity so wear your SPF 30 sunscreen daily!

Please be aware that this study was only run for 12 weeks and that while initial improvement was seen, plan for a 12 month course of therapy to see your maximum results.

In which order will you apply your creams?

Microdermabrasion may also be a helpful procedure to consider for stubborn, older white stretch marks. Microdermabrasion is a procedure where tiny particles are basically "sand blasted" against the skin and gradually remove scarred or discolored epidermal tissue. Microscopic studies have supported the effectiveness of microdermabrasion. This procedure is performed in a variety of settings from dermatologist and plastic surgery offices to some spas and high end aesthetician clinics, or you can try it yourself with DermaNew Total Body Experience Kit. This is done in a series of typically 6 or more treatments depending upon the type of problem being treated. Alone I do not personally think that microdermabrasion is going to be your solution, but in combination with a proven regimen it may help hasten your improvement.

A final potential option for the treatment of older stretch marks is the new N-Lite laser. While it is FDA approved for the treatment of periorbital wrinkles (a nice way of saying crow's feet), a potential "off label" use may be to help improve the appearance of stretch marks. The N-Lite is a non-ablative laser, meaning there is no burning of the skin as seen in routine ablative laser resurfacing. The N-Lite helps stimulate the fibroblasts to start producing collagen fibers. If you plan to try this procedure, I would truly assume you will need at least 3 sessions before you determine if it has been effective.

Pregnant Pause

It is estimated that 90% or more of pregnant Caucasian women will develop stretch marks. That's huge! Women of color tend to fair better but still can be at risk for developing stretch marks. Genetics as always tend to play a role, particularly in the possible severity of your stretch marks. So, if your mother has really bad stretch marks odds are you will too. During pregnancy those adrenocorticoids are circulating in high concentrations, and while they are the major culprit, it is hypothesized that other hormones such as estrogen and relaxin may also play a role.

As the physical stretching contributes to location as well as direction of stretch marks, it is obvious that the breasts, buttocks, thighs and abdomen will be most likely afflicted. Stretch marks formed during pregnancy can improve without intervention, but they never seem to fully go away. The next baby shower you go to; consider taking a tube of Mederma or a bottle of Cellex-C High Potency Serum. Your mother-to-be will welcome the opportunity to do something constructive for her rapidly changing form. And rest assured, Mederma, Cellex-C High Potency Serum and Priori Advanced AHA Hand & Body Revitalizing Lotion (if used) are all safe to use while pregnant or nursing.

Young and Jewel published a study in 1995 on "Creams For Preventing Stretch Marks In Pregnancy". In it they looked at 100 women who had at least one birth behind them and had developed stretch marks and were pregnant again. A cream composed of a mixture of a botanical ingredient Centella asiatica (also known as Gotu Kola) combined with Vitamin E (alpha tocopherol) and collagen-elastin hydrolysates was applied to the skin and found to have some benefit to preventing the formation of stretch marks.

I was pretty excited by this Cochran Review until I went looking to find out more on Centella asiatica. It turns out that when taken by mouth as a supplement it can cause miscarriage and has a narcotic-like effect. It is not to be used if pregnant or nursing. In addition it is known to cause a rash or increased sun sensitivity when applied topically. I would be incredibly hesitant to ask a pregnant woman to apply any cream with an ingredient known to be dangerous if taken orally. Currently we go to great lengths to discourage the use of topical vitamins A and K for pregnant women, so I would add this to the list. For those of you ingredient readers, other names for Centella asiatica include Hydrocotyle asiatica, Indian Pennywort, Indian Water Navelwort and Marsh Penny. Incidentally, researchers felt that this mixture was of no benefit for treating or preventing routine stretch marks.

Growing, Growing, Growing, Gone!

To be honest I always thought that all that stretching associated with growth spurts was responsible for stretch marks in adolescence. At least 35% of girls and 15% of boys will develop stretch marks at some point during puberty. The actual cause of developing stretch marks when you're growing is an increase in 17-ketosteroid circulating throughout the bloodstream. You can't do anything to stop that, but you can be aware of the problem and plan ahead.

And what about your teenagers? More than likely most teens are not going to bring up their concerns to you. They are far too body conscience to count on them requesting help. So bring up the subject. Ask them if they are seeing red or white streaks on their skin. They probably have no idea of what is happening to them and will be thrilled at trying anything to clear them up.

I think if parents were better educated on this that we could have teens treating these stretch marks early on and ideally prevent much of the aftermath of white lines coursing across their skin. I would suggest taking the pregnancy approach and either use prevention with topical Vitamin C serums like Cellex-C High Potency Serum or start applying Mederma once you start seeing them form.

As with all white stretch marks, if your are from a growth spurt long gone you need to handle them exactly as detailed above in "White Out."

You may stretch, but the stretch marks won't hide. Be thankful that researchers are finding new options all the time to help improve the appearance of those "badges of life" we wear upon our skin.

Thank you for taking the time to read my newsletter about Stretch Marks. As always, I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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