الفهرس 
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Abstract
Striae distensae are atrophic linear skin lesions resulting from rapid stretching of the weak connective tissue of the dermis. They initially begin as red elevated lesions (striae rubrae) which gradually become atrophic depressed and white scars (striae albae). Various treatment modalities have been applied to improve appearance of SD including topicals, chemical peels, ultrasound therapy, MDA, fractional photothermolysis, PRP, IPL, PDL and RF with variable unpredictable outcomes.
In the present study, 37 female patients with SD (rubrae or albae) were included with mean age of the patients was 23.8 ± 5.5 years and 22 patients with SD (59.5%) were residents in urban and suburban areas. Family history of SD was positive in 26 patients (70.3%). SD were of a gradual onset in 32 patients (86.5%) and progressive course in 19 patients (51.4%). The mean duration of SD was 5.4 ± 5.1 years.
As regard the clinical assessment of SD, 18 patients (48.6%) were of moderate severity of SD. Trunk was the most common affected site with SD in 18 patients (48.6%) followed by affection of more than one body site in 16 patients (43.2%). Pregnancy was the most common underlying cause of SD in 18 patients (48.6%) followed by puberty in 12 patients (32.4%). Fitzpatrick skin type III was found in 28 patients (75.7%). Striae albae was found in 21 patients (56.8%). The mean width of striae before treatment was 5.3 ± 4.6 mm.
Concerning the comparison between the three treatment modalities of SD, clinical improvement was observed early from the 2nd session in group B (patients treated with PRP) and group C (patients treated with fractional CO2 laser) but late clinical improvement from the 4th session was observed in group A (patients treated with carboxytherapy).
A statistical significant difference was found between group B & C as regard the mean width after treatment in favor of group C (P value=0.044) and between group A & C as regard the percentage of change in the width which was also in favor of group C (P value=0.042).
The highest statistical significant decrease in width of SD was observed in group C followed by group B then group A. The highest ratio of improvement (from mild to marked) of the skin texture and the overall improvement were observed in group C followed by group B then group A.
As regard assessment of the histopathological changes, epidermal atrophy with flattening in rete ridges and decreased collagen bundles were noted in all biopsies from SD patients before treatment, while after treatment, there was variable increase in the epidermal thickness and increase in rete ridges formation These changes were more evident in striae albae than striae rubrae. According to the modified scoring system for the dermal histopathological changes after treatment; marked improvement was more obvious in group A followed by group C then group B while moderate improvement was more evident in group B followed by group C then group A.
According to the agreement between clinical and histopathological improvement in the three groups, mild statistical agreement was found and 77.8% of cases showed the same extent of clinical and histopathological improvement. All cases (100%) showed histopathological improvement ranging from mild to marked; whereas 81.5% of cases showed mild to marked clinical improvement and 18.5% of cases showed no clinical improvement. This indicates that the histopathological improvement mostly precedes the clinical improvement and more treatment sessions are needed for the clinical improvement to keep up the histopathological improvement.
In the current study, total patient’s and dermatologist’s satisfaction were the highest in group C followed by group A then group B. As regard the safety and tolerability of the three treatment modalities, all the recorded side effects were transient. Pain during the treatment sessions was found in 100% of cases in group B, while crackling sensation was observed in 25% of cases in group A. Erythema and PIH were detected in group C in 100% and 91.7% of cases respectively. PIH disappeared gradually during the follow up period either spontaneously in 36.4% of cases or after using whitening creams in 63.6% of cases on the affected areas.
Based on the multivariate analysis of the effect of prognostic factors on SD response to treatment in the three groups, no statistical significant relation was found between the site, type, severity, duration of SD, skin type or the age of patients except in group B, where a negative statistical significant correlation was found between the overall improvement and the duration of SD.
The three treatment modalities gave better results in patients with skin type III. Carboxytherapy and fractional CO2 laser showed better improvement in moderate to severe striae albae; while PRP showed better results with mild to moderate striae rubrae. Carboxytherapy and PRP showed higher percentage of improvement in SD affecting more than one body sites, while better improvement with fractional CO2 laser was found in SD affecting trunk.
Conclusions
In the current study, we concluded that carboxytherapy, PRP and fractional CO2 laser were clinically and histopathologically effective and safe treatment options for mild to severe SD, however fractional CO2 laser was more effective especially in cases of moderate to severe striae albae with early clinical improvement which was observed from the 2nd treatment session. It showed higher patient and dermatologist’s satisfaction rate, good safety profile and tolerability but it was costy. Carboxytherapy is also a safe and effective and showed the highest percentage of marked histopathological improvement. PRP is a cheap, safe and simple in-office technique which is beneficial in cases of mild to moderate striae rubrae.
The results of the present study are considered as a base for further studies to assess the efficacy of fractional CO2 lasers in treating SD, with trying different number, frequency of sessions and different parameters in order to achieve the optimum effectiveness. Changing parameters of fractional CO2 laser according to the skin type “lowering energy in darker skin types” and usage of whitening creams in between sessions are recommended to avoid PIH.
Further studies with larger sample size and more number of treatment sessions are recommended for better results especially in case of using carboxytherapy which needs larger number of treatment sessions to establish clinical improvement and this is considered a limiting factor for such method, so it’s recommended not to rush for rapid clinical response. PRP is recommended in cases of striae rubrae or SD of short duration. Combined therapy is recommended for more improvement in SD such as combination of PRP with microneedling, MDA, topical retinoids or carboxytherapy and combination of fractional CO2 laser with MNRF.
Application of histochemical stains (ex. Picrosirus red stain or Masson trichrome stain) is recommended to raise the percentage of agreement between clinical and histopathological improvement and to highlight the recent newly formed collagen.