Treatment of Striae Distensae with Fractional Photothermolysis

HANA BAK, MD, BEOM JOON KIM, MD,y WOO JIN LEE, MD, JANG SEOK BANG, MD,z
SUN YOUNG LEE, MD,y JEE HO CHOI, MD, AND SUNG EUN CHANG, MD

BACKGROUND Striae distensae are dermal scars characterized by flattening and atrophy of the epidermis. Although many treatment modalities have been tried with variable results, most have been
disappointing.
OBJECTIVE

To determine whether striae distensae might respond to fractional photothermolysis.

METHODS Twenty-two women with striae distensae were treated with two sessions each of fractional
photothermolysis at a pulse energy of 30 mJ, a density level of 6, and eight passes at intervals of 4
weeks. Response to treatment was assessed by comparing pre- and post-treatment clinical photography
and skin biopsy samples.
RESULTS Six of the 22 patients (27%) showed good to excellent clinical improvement from baseline, whereas the other 16 (63%) showed various degrees of improvement. Most of the lesions with
excellent results were white in color and of long duration. Skin biopsy revealed that average epidermal
thickness and dermal thickness were greater than at baseline. The immunoreactivity of procollagen
type 1 increased after treatment. There were no significant side effects except erythema and mild pigmentation.
CONCLUSION Fractional photothermolysis may be effective in treating striae distensae, without significant side effects. Treatment outcomes were better in patients with white rather than red striae.
The authors have indicated no significant interests with commercial supporters.

triae distensae, a common skin condition, do not

cause any significant medical problems, but they
can be of significant distress to those affected. Striae
are commonly observed in association with pregnancy, obesity, growth during adolescence, increased
adrenocortical function, and corticosteroid therapy.
Striae initially appear as pink to purple atrophic
bands sometimes associated with mild pruritus.1
Their exact cause is unknown, although a combination of hormonal factors associated with lateral
stretch due to increased size of the various portions
of the body is thought to be important. It mainly
occurs on the abdomen and buttocks and sometimes
breasts. Histopathologically, they are characterized
by thinning of the overlying epidermis, with fine
dermal collagen bundles arranged in straight parallel
lines.2 In their early stages, inflammatory changes

are conspicuous, with elastolysis accompanied by

mast cell degranulation, followed by activated macrophages that envelop fragmented elastic fibers.3 In
later stages, the dermal collagen is layered in thin
eosinophilic bundles oriented in straight lines.4
Many treatment modalities have been tried, including topical application of tretinoin, pulsed dye laser,
and intense pulsed light, with variable results.57
Although fractional photothermolysis can be used to
treat facial rhytides, acne scars, surgical scars,
melasma, and photodamaged skin, to our knowledge, there have been only a few reports of fractional
photothermolysis for the treatment of striae
distensae.810 The objective of this study was to
evaluate the safety and efficacy of fractional photothermolysis in the treatment of striae distensae.

Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea;
y

Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Korea; zMeline Dermatology Clinic,
Seoul, Korea; yGowoonsesang Dermatology Clinic, Seoul, Korea
& 2009 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc. 
ISSN: 1076-0512  Dermatol Surg 2009;35:12151220  DOI: 10.1111/j.1524-4725.2009.01221.x
1215

T R E AT M E N T O F S T R I A E D I S T E N S A E W I T H F R A C T I O N A L P H O T O T H E R M O LY S I S

Methods
Twenty-two Asian women (aged 3246; mean age
36) clinically diagnosed with striae distensae and not
previously treated using any medical or surgical
methods were enrolled. The duration of striae
ranged from 1 to 16 years (average 6 years).
Childbirth caused striae in 18 patients and weight
gain in five. All patients provided written informed
consent, and the local ethics committee approved
the study protocol.
Each patient underwent two laser treatments, at
4-week intervals. Treatment sites included the
abdomen in 15 subjects, the arms in two, the buttocks in 10, the back in five, and the thighs in five.
One hour before each treatment, patients were
anesthetized with topical 30% lidocaine gel. A blue
dye (FD&C No. 1) was used to demarcate the areas
of laser treatment, serving as a guide marker for the
intelligent optical tracking device of the laser
handpiece. Each treatment session consisted of a
pulse energy of 30 mJ, a density level of 6, and eight
passes. Patients were instructed to avoid the use of
any therapeutic agents during the course of treatment. Treatment responses were assessed by comparing pre- and 4-week post-treatment clinical
photography and skin biopsy.
Skin biopsy samples were taken from the most
atrophic site before treatment and 1 month after the
second laser treatment. The excised skin was fixed in
10% formalin and embedded in paraffin. Threemicrometer-thick sections were stained with
hematoxylin and eosin (H&E), Masson-trichrome,
and Elastica von Gieson stains. Two dermatologists
masked to time of sampling evaluated the
histopathologic results.

Samples from two patients were stained with antibodies to procollagen 1, elastin, and matrix metalloproteinase (MMP)-1, followed by incubation with
fluorescein isothiocyanateconjugated secondary
antibody (Sigma, St. Louis, MO). Samples were
viewed under an Olympus BX 50 fluorescence

1216

D E R M AT O L O G I C S U R G E RY

microscope (Olympus, Tokyo, Japan) equipped for

epifluorescence using appropriate filters. Selected
images were further analyzed through a Leica TCSSP-2 laser scanning confocal microscope (LSCM)
(Leica Microsystems, Heidelberg, Germany).
Epidermal and dermal thicknesses of biopsy specimens were measured using an optic micrometer, and
results were compared in individual patients and as
an average. Statistical analysis used the Excel onetailed t-test for small paired samples.
Clinical photographs were taken at each visit. No
severe side effects were recorded. Two nontreating
blinded dermatologists analyzed improvements, as
determined photographically, using a quartile grading scale of 1 (o25%, mild), 2 (2550%, moderate),
3 (5175%, marked), and 4 (76100%, excellent).
In addition, a patient satisfaction score (A = not satisfied, B = somewhat satisfied, and C = highly satisfied) was recorded after completion of treatment.

Results
One month after the final treatment, six of 22 (27%)
patients showed marked improvement in the striae
(Table 1, Figure 1), with the other 16 showing mild
(grade 1) improvement. On the quartile grading
scale, the mean clinical improvement 1 month after
treatment was 1.5. The treated striae demonstrated
various improvements in color, with all those
showing excellent results being white (Table 1).
There were no significant differences according
to anatomic site.
H&E and Masson-trichrome staining showed that
average epidermal thickness (0.24 to 0.55 mm,
po.05) and dermal thickness (1.97 to 4.03 mm,
po.01) were greater after treatment than at baseline
(Figure 2, Table 1). Elastica von Gieson staining
gave similar results before and after treatment.
Pretreatment atrophy was noted in all patients.
LSCM analysis showed marked increases in the
immunoreactivity of procollagen type 1 one month

BAK ET AL

TABLE 1. Clinical Improvement and Changes in Epidermal and Dermal Thicknesses

Patient
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
21
Sum
Average

Color of the
Distensae

Average Clinical
Improvement

White
Purple
White
Purple
Pink
Pink
Pink
Pink
Pink
Pink
Purple
Pink
Pink
White
Pink
Pink
Pink
White
Pink
Pink
White
White

3
1
2
1
1
1
1
1
1
1
1
1
1
2
1
1
1
3
1
1
4
3
33
1.5

Epidermal Thickness
Pre/Post

Dermal Thickness
Pre/Post

0.02/0.06
0.13/0.23
0.03/0.04
0.05/0.05
0.06/0.06
0.75/0.95
0.11/0.15
0.05/0.18
0.09/1.03
0.08/0.15
0.12/0.25
0.04/0.08
0.91/1.15
0.08/1.02
0.04/0.09
0.07/1.02
0.75/1.25
0.94/1.18
0.18/0.23
0.09/1.03
0.52/1.12
0.07/0.83
5.18/12.15
0.24/0.55

1.5/4.3
2.07/3.8
2.0/3.7
1.5/2.3
1.95/5.3
1.85/3.45
2.05/3.7
2.35/3.35
2.0/4.05
1.05/4.5
1.95/3.9
2.33/3.3
1.21/3.35
1.68/4.50
2.31/3.75
2.09/5.55
1.97/4.21
2.98/4.05
1.65/4.3
1.96/4.03
2.13/3.74
2.76/5.63
43.34/88.76
1.97/4.03

Average of the two observers.

after the end of treatment (Figure 3) but no changes

in the immunoreactivity of elastin and MMP-1.
The treatment was well tolerated. The patients described the procedure as mildly to moderately uncomfortable. There were no significant side effects
except mild erythema and pigmentation. Postlaser
erythema and crusts, lasting 1 day to 2 weeks, were
observed in all patients, whereas postinflammatory
hyperpigmentation was observed in only two of 22
patients. Allergic contact dermatitis to the anesthetic
topical gel was observed in one patient. Patient satisfaction surveys paralleled the clinical improvements.

Discussion
Striae distensae are dermal scars characterized by
linear atrophic depressions. Many treatment modalities have been tried, with variable results. Topical

tretinoin cream was shown to improve appearance,5

and glycolic acid and ascorbic acid have had variable
outcomes.11 Intense pulsed light was shown to be
successful in the treatment of striae alba, but postinflammatory pigmentation occurred in 40% of patients.7 The 308-nm excimer laser has been shown to
temporarily repigment striae alba without improving
atrophy.1214 Treatment of striae distensae with
pulsed dye, carbon dioxide, and 1,450-nm diode
lasers have also been attempted.6,1517
Fractional photothermolysis uses arrays of microscopic thermal damage patterns to stimulate a therapeutic response.8 These arrays are produced in
various patterns by focusing the laser beam at specific depths in the dermis. The tiny areas of thermal
injury surrounded by uninjured tissue are called microscopic treatment zones (MTZs). MTZ density
and the space between MTZs can be varied for a

35:8:AUGUST 2009

1217

T R E AT M E N T O F S T R I A E D I S T E N S A E W I T H F R A C T I O N A L P H O T O T H E R M O LY S I S

Figure 2. Skin biopsies of (A) an untreated abdominal striae

and (B) the same abdominal striae 1 month after final treatment. Note the increased collagen in the dermis and a microthermal zone (arrows) with columns of altered collagen
(Masson trichrome  200).

specific target tissue. Because uninjured tissue

surrounds each MTZ, keratinocytes have a shorter
migration path, and healing is much quicker. Fractional photothermolysis recently showed effectiveness in the treatment of atrophic scars,18 suggesting
that the approach might also improve striae, and few
reports have described the use of fractional photothermolysis in the treatment of striae distensae.9,10 In
this study, we used fractional photothermolysis (the
Fraxel SR 1500 laser), which can penetrate up to
30% deeper than other lasers, delivering consistent
dosage control and optimizing lesion depths.
Our results suggest that this method may result in
clinical and histopathologic improvement of striae

Figure 1. One patient with striae alba had (A) the lesions on
the left upper arm at baseline and (B) the improved lesions 1
month after two treatment sessions and (C) the lesions on
the right upper arm at baseline and (D) the improved lesions
1 month after two treatment sessions. Another patient with
striae rubra had no significant changes between (E) baseline
and (F) 1 month after two treatment sessions.

given energy level. In fractional photothermolysis,

tissue damage occurs in microscopic columns that
extend into the dermis and is not restricted to a

1218

D E R M AT O L O G I C S U R G E RY

Figure 3. Laser scanning confocal microscopy of (A) an untreated abdominal striae and (B) the same striae 1 month
after final treatment, showing greater dermal immunoreactivity with antibody to procollagen type 1.

BAK ET AL

distensae. All striae that showed excellent improvement were white, suggesting that fractional
photothermolysis is most effective for patients with
late-stage white striae. Long-term follow-up has
confirmed these results. Six months after the last
treatment, three of three patients with striae alba had
shown subjective improvement, whereas only two of
eight patients with striae rubra had improved
slightly, with the other six being in stationary state.
Histopathologically, a marked decrease in collagen
fibers and elastic tissues with thinned epidermis because of a flattening of the rete ridges characterize
late-stage striae. In early-stage striae, these findings
are less prominent, with perivascular infiltrates of
inflammatory cells being the predominant feature.
Thus, fractional photothermolysis, which induces
epidermal and dermal collagen regeneration, is especially effective in the treatment of striae alba. The
limited therapeutic outcome observed in many of our
patients may have been because of their early-stage
striae (mean 6 years).6,16,19 There were no statistically significant differences between anatomic sites.
Similar to previous reports, the side effects of treatment were transient and limited to erythema, edema,
and pigmentation.20 No other adverse effects were
observed, including acneiform eruptions or herpes
simplex virus outbreaks.

References

Although we observed clinical improvements

1 month after two sessions of fractional photothermolysis, additional studies are necessary to determine the longevity of improvement. Optimization
of treatment protocols should be established through
clinical trials involving larger numbers of patients. In
addition, long-term side effects, complications, and
efficacy of treatment have yet to be established, necessitating further research to confirm our results.

12. Goldberg DJ, Sarradet D, Hussain M. 308-nm Excimer laser

treatment of mature hypopigmented striae. Dermatol Surg
2003;29:5969.

Summary
Treatment of striae distensae with fractional photothermolysis was effective and without significant
side effects. Treatment outcomes were better in patients with striae alba than in those with striae rubra.

1. Requena L, Sanchez-Yus E. Striae distensae. Dermatopathol Pract

Concept 1997;3:197202.
2. Zheng P, Lavker RM, Kingman AM. Anatomy of striae. Br J
Dermatol 1985;112:18593.
3. Sheu HM, Yu HS, Chang CH. Mast cells degranulation and
elastolysis in the early stage of striae distensae. J Cutan Pathol
1991;18:4106.
4. Watson RE, Parry EJ, Humphries JD, et al. Fibrillin microfibrils
are reduced in skin exhibiting striae distensae. Br J Dermatol
1998;138:9317.
5. Kang S, Kim KJ, Griffiths CEM, et al. Topical tretinoin (retinoic
acid) improves early stretch marks. Arch Dermatol
1996;132:51926.
6. Jimenez GP, Flores F, Berman B, Gunja-Smith Z. Treatment of
striae rubra and striae alba with the 585-nm pulsed-dye laser.
Dermatol Surg 2003;29:3625.
7. Hernandez-Perez E, Colombo-Charrier E, Valencia-Ibiett E. Intense pulsed light in the treatment of striae distensae. Dermatol
Surg 2002;28:112430.
8. Hasegawa T, Matsukura T, Mizuno Y, et al. Clinical trial of a laser
device called fractional photothermolysis system for acne scars.
J Dermatol 2006;33:6237.
9. Kim BJ, Lee DH, Kim MN, et al. Fractional photothermolysis for
the treatment of striae distensae in Asian skin. Am J Clin
Dermatol 2008;9:337.
10. Taub AF. Fractionated delivery systems for difficult to treat clinical applications: acne scarring, melasma, atrophic scarring, striae
distensae, and deep rhytides. J Drugs Dermatol 2007;6:11208.
11. Ash K, Lord J, Zukowski M, McDaniel DH. Comparison of
topical therapy for striae alba (20% glycolic acid/0.05% tretinoin
versus 20% glycolic acid/10% L-ascorbic acid). Dermatol Surg
1998;24:84956.

13. Alexiades-Armenakas MR, Bernstein LJ, Friedman PM, Geronemus RG. The safety and efficacy of the 308-nm excimer laser for
pigment correction of hypopigmented scars and striae alba. Arch
Dermatol 2004;140:95560.
14. Goldberg DJ, Marmur ES, Schmults C, et al. Histologic and ultrastructural analysis of ultraviolet B laser and light source treatment of
leukoderma in striae distensae. Dermatol Surg 2005;31:3857.
15. Nouri K, Romagosa R, Chartier T, et al. Comparison of the 585
nm pulse dye laser and the short pulsed CO2 laser in the treatment
of striae distensae in skin types IV and VI. Dermatol Surg
1999;25:36870.
16. Tay YK, Kwok C, Tan E. Non-ablative 1,450-nm diode laser
treatment of striae distensae. Lasers Surg Med 2006;38:1969.
17. Goldman A, Rossato F, Prati C. Stretch marks: treatment using
1,064-nm Nd:YAG laser. Dermatol Surg 2008;34:68692.
18. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser photothermolysis for the treatment of atrophic scars. Dermatol Surg
2007;33:2959.

35:8:AUGUST 2009

1219

T R E AT M E N T O F S T R I A E D I S T E N S A E W I T H F R A C T I O N A L P H O T O T H E R M O LY S I S

19. Suh DH, Chang KY, Son HC, et al. Radiofrequency and 585-nm
pulsed dye laser treatment of striae distensae: a report of 37 Asian
patients. Dermatol Surg 2007;33:2934.
20. Graber EM, Tanzi EL, Alster TS. Side effects and complications of
fractional laser photothermolysis: experience with 961 treatments. Dermatol Surg 2008;34:3017.

1220

D E R M AT O L O G I C S U R G E RY

Address correspondence and reprint requests to: Sung Eun

Chang, MD, Department of Dermatology and Research
Institute of Dermatology, University of Ulsan College of
Medicine, Asan Medical Center, 388-1 Pungnapdong Songpagu, Seoul, 138-736 Korea, or e-mail: cse@amc.seoul.kr