23 July 2018
Turning the blog focus on to something very close to my heart: pregnancy. Some of you might know that I am a new mother to a very young rascal; and like everyone else, had my own share of ebbs and flows during and after pregnancy. Pigmentation, dull skin, hair loss and stretch marks were a few of the problems I faced after I delivered. I’ll be sharing more about these problems in future posts but today I’ll take you through a subject sensitive to most mothers: stretch marks.
A good number of my close friends are new mothers-to-be, and I could not possibly be happier for them. I find that there is a considerable amount of misinformation and old wives’ tales when it comes to stretch marks and pregnancy, so through this educational post from both a doctor and doctor, mother and friend; I hope you find that this post on stretch marks useful. Remember, science always wins.
Stretch marks are also known as ‘striae’ and are the silver-white marks that you see on the abdomen, breasts, buttocks arms and thigh, where the skin has been stretched.
Stretch marks first appear as red-purple wrinkled lines across the skin in the initial stages (striae rubrae) and they fade to become silver-white and indented over time (striae albae). In the second layer of the skin called the dermis, which is below the epidermis, collagen, elastin fibres and blood vessels also get stretched. If we were to look at the dermis under a microscope after the skin has been stretched, we will see that stretch marks are very similar to scars. There is thinning of the skin with decreased collagen and elastin fibres and changes to the blood vessels.
Stretch marks occur when the skin has been stretched mechanically in situations such as pregnancy, rapid growth spurts during puberty, weight gain and high BMI. If you feel alone in your stretch mark woes, take heart that you are not the only one- studies have shown that 90% of pregnant women develop stretch marks in their third trimester of their pregnancy. There are other factors that also affect your predisposition to getting stretch marks such as your genetics, vitamin C level, baby’s weight… etc. We also see stretch marks in patients on long term steroids because steroids decrease the collagen and elastin levels in the skin.
Topical stretch mark creams
Topical cream touting to prevent stretch marks are aplenty in the market and I diligently applied copious amounts of stretch mark creams during my pregnancy. Most of these creams contain shea butter, cocoa butter and olive oil and are generally safe for pregnant and nursing mums.
The stretch mark cream that I used was Clarins® Stretch Mark Cream. The active ingredients are Crowberry and Centella Asiatica extracts, olive, coconut and palm oils and siegesbeckia. Despite the popularity it enjoys as a stretch mark cream in Singapore, there no trials to prove the claims or efficacy of this stretch mark cream.
But did I think that my modest investment in stretch mark creams worked? Objectively, it is hard to say what my skin would have looked like without using these stretch mark creams; although I am satisfied with the results. Typically, the active ingredients in stretch mark creams consist of Vitamin E (Trofolastin, Alphastria, olive oil, cocoa butter and Verum) as well as hyaluronic acid (which are also present in Alphastria and Verum). Vitamin E promotes collagen formation in the skin and is a powerful antioxidant. Hyaluronic acid is thought to reduce stretch mark by stimulating collagen formation in the skin, thereby maintain skin elasticity and tone.
A review of 11 studies showed that Trofolastin and Alphastria (which contain Vitamin E and hyaluronic acid) as active ingredients in stretch mark creams showed some benefits with stretch marks and retinoids (a category C drug, not to be used during pregnancy and lactation!) showed varying benefits. There was no evidence of benefit for olive oil and cocoa butter.
Weight gain, diet and exercise
Since we know that rapid weight gains stretch the skin and damage the collagen and elastin fibres in the skin and blood vessels; aim for a healthy and gradual weight gain to avoid this sudden stress on the skin. There is a paucity of evidence that shows that diet and exercise can prevent the formation of stretch marks, but having a healthy lifestyle is important for your general health and helps to prevent drastic weight gains and stresses on the skin.
Fractional CO2 lasers for stretch marks
Lasers, specifically fractional CO2 lasers have been used to treat various types of scars including stretch marks, acne scars and scars from trauma. Fractional CO2 laser is very effective at treating scars and is also regarded as the gold standard for treatment of depressed acne scars.
Fractional CO2 lasers penetrate the surface of the skin to reach the dermis to stimulate breakdown of the stretch marks and formation of collagen and elastin. This leads to growth of new and healthy skin over the stretch mark scars. Studies have shown that fractional CO2 laser for stretch marks is an effective treatment with positive outcomes.
Examples of fractional CO2 devices are the Edge fractional CO2 laser.
Radiofrequency (RF) for stretch marks
Radiofrequency devices have been offered for stretch mark treatments; however, they are better for skin tightening and results with the results of scar treatments are still better with fractional CO2 laser.
Intense Pulsed Light (IPL)
A favourite service of beauty salons and spa, intense pulsed light has been touted as a panacea to many skin problems, to much disappointment of clients. IPL is a treatment with specific uses and the treatment of stretch marks is not one of them. At best, IPL reduces the discolouration of early stretch marks but do not improve the appearance of stretch marks when they become silvery white. A study that compared the outcomes of stretch mark treatment with fractional CO2 laser and IPL showed that fractional CO2 laser for stretch marks had better results.
Vitamin A/Tretinoin/ Retinoic acid
Retinoids increase collagen formation in the skin studies and small studies have shown that with daily use over a period of at least 6 months, stretch marks can be reduced. However, retinoids are a pregnancy category C drug and should be avoided in pregnancy and breastfeeding.
Although stretch marks are a very common problem, stretch marks are not well studied when it comes to prevention and treatment of stretch marks. I would say that when it comes to prevention of stretch marks, aim for a healthy and gradual weight gain together with your obstetrician. Key to this is having a healthy diet and lifestyle. Stretch mark creams are not that useful, but are generally safe if you still wish to use them.
Once the stretch marks have formed, the two main treatments that have been shown to work are retinoids (avoid during pregnancy and breastfeeding) and fractional CO2 laser. The earlier that you seek treatment for your stretch marks scars, the better outcome.
1. Therapeutic targets in the management of striae distensae: A systematic review. Hague and Bayat. J Am Acad Dermatol. 2017 Sep;77(3):559-568
2. Striae Distensae: Preventative and Therapeutic Modalities to Improve Aesthetic Appearance. Ross et al. Dermatol Surg. 2017 May;43(5):635-648.
3. Genome-wide association analysis implicates elastic microﬁbrils in the development of nonsyndromic striae distensae. Tung et al. J Invest Dermatol 2013;133:2628–31.
4. Striae distensae: an ultrastructural investigation. Gilmore, Rolfe and Wurm. Exp Dermatol 2011;20:e872.
5. Topical management of striae distensae (stretch marks): prevention and therapy of striae rubrae and albae. Ud‐Din, McGeorge and Bayat. J Eur Acad Dermatol Venereol. 2016 Feb; 30(2): 211–222.