Topical management of striae distensae (stretch marks): prevention and therapy of striae rubrae and albae
Abstract
摘要
英文原文
Striae distensae (SD) are common dermal lesions, with significant physical and psychological impact. Many therapeutic modalities are available but none can completely eradicate SD. The most common therapy is the application of topicals used both therapeutically and prophylactically. Even though there are many commercially available topical products, not all have sufficient level of evidence to support their continued use in SD. The aim here was to assess the evidence for the use of topicals in SD and to propose a structured approach in managing SD. A systematic search of published literature and manufacturer website information for topicals in SD was carried out. The results showed that there are few studies (n=11) which investigate the efficacy of topicals in management of SD. Trofolastin and Alphastria creams demonstrated level-2 evidence of positive results for their prophylactic use in SD. Additionally, tretinoin used therapeutically showed varying results whilst cocoa butter and olive oil did not demonstrate any effect. Overall, there is a distinct lack of evidence for each topical formulation. The majority of topicals failed to mention their effect on early vs. later stages of SD (striae rubrae compared to striae albae) and their role in both prevention and treatment. In conclusion, there is no topical formulation, which is shown to be most effective in eradicating or improving SD. A structured approach in identification and targeted management of symptoms and signs with the appropriate topical is required. Randomized controlled trials are necessary to assess the efficacy of topical products for treatment and prevention of different stages of SD.
对应中文
膨胀纹（striae distensae，SD，也可称为strech mark）是常见的皮肤病变，对身体和心理都有重大影响。有许多治疗方法可用，但没有一种能完全根除SD。最常见的治疗方法是局部使用，既用于治疗，也用于预防。尽管有许多商业上可用的局部产品，但没有一家公司有足够的证据支持它们在SD中继续使用。这里的目的是评估在SD中使用专题药物的证据，并提出一种结构化的方法来管理SD。本文对SD相关的文献和厂商网站信息进行了系统的检索。结果表明，有关外用药物治疗SD疗效的研究较少(n=11)：其中，Trofolastin乳霜 和Alphastria乳膏证明了其在SD预防性应用中的2级阳性结果；用于治疗的维甲酸在不同的研究中显示出不同的效果；而可可脂和橄榄油没有显示出任何效果。总的来说，每种外用制剂都明显缺乏证据。大多数局部用药未提及其对SD早期和晚期的影响（红纹与白纹相比）及其在预防和治疗中的作用。综上所述，不存在被证明在根除或改善SD方面最有效的局部配方。需要一种结构化的方法来识别和有针对性地管理症状和体征，并提供适当的局部护理。随机对照试验对于评估外用药物治疗和预防不同阶段SD的疗效是必要的。
Introduction
引言
英文原文
Striae distensae (SD) or stretch marks are common dermal lesions which arise due to the stretching of the dermis.There are two forms of SD; striae rubrae and striae albae.The acute stage (striae rubrae) is characterized by the initial erythematous, red and stretched flat (in some cases appear slightly raised) lesions which are aligned perpendicular to the direction of skin tension and can be symptomatic, whilst the chronic stage (striae albae) is classified when SD have faded and appear atrophic, wrinkled, and hypopigmented.
对应中文
膨胀纹（SD）是由于真皮拉伸而产生的常见皮肤病变。SD有两种形式；红纹和白纹。急性期(红纹)表现为初始红斑、红色和伸展的扁平灶(有些病例表现为轻度隆起)，垂直于皮肤张力方向排列，可表现为无症状；慢性期(白纹)则表现为SD消退，出现萎缩、皱纹和色素减退。
英文原文
There are a number of pathological and histological changes which occur when SD are formed. Elastolysis of the middermis is evident due to mast cell degranulation and stimulation of macrophages.Other observations include perivascular lymphocytic cuffing, increased glycosaminoglycan, sporadic presence of lymphocytes and oedema in the dermis.Gradual atrophy of the epidermis has been noted including loss of rete ridges.Vascular changes occur which contribute to the red and erythematous appearance of striae rubrae.Additionally, in striae rubrae, collagen fibres become thicker, more densely packed, are arranged in a parallel pattern and show a reduction in elastic fibres.Conversely, striae albae have less vascularity and tend to be very pale in colour.Striae albae have been described as appearing similar to mature and flattened, or stretched dermal scars.
对应中文
SD形成时会发生许多病理和组织学变化。由于肥大细胞脱颗粒和巨噬细胞的刺激，真皮中段的弹性组织离解很明显。其他观察结果包括血管周围淋巴细胞袖套、糖胺聚糖增加，真皮中偶尔出现淋巴细胞和水肿。既往研究曾发现SD相关的表皮渐行性萎缩，包括网嵴消失。还有血管的变化，因此红纹才出现红色和红斑。此外，红纹中的胶原纤维变得更厚、更密集，呈平行排列，而弹性纤维显示减少。相反，白纹的血管较少，颜色较浅。白纹被描述为类似于成熟、扁平或拉伸的真皮疤痕。
Figure
图
Illustration demonstrating the common anatomical loca- tions affected by striae distensae.
常见易产生膨胀纹的解剖部位如图所示。
英文原文
The causes of SD are proposed to be due to the mechanical effect of tissue stretching;from growth in adolescence and rapid increase in the size of certain locations of the body.The most common anatomical locations which are affected by SD are the abdomen, breasts, buttocks and thighs.
对应中文
SD的原因被认为是由于组织拉伸的机械效应，比如从青春期开始生长和身体某些部位的尺寸迅速增加。受SD影响的最常见的解剖位置是腹部、乳房、臀部和大腿。
英文原文
Striae distensae have presented a considerable challenge in terms of both their evaluation and treatment. There are variable responses to therapies, with the main aims being reduction in symptoms and improvement in appearance. Various treatment modalities exist which aim to treat or prevent SD such as laser therapy,light therapy,acid peel treatments,collagen injection,laser lipolysis,radiofrequency techniques and microdermabrasion.No single therapy has been advocated to completely eradicate these lesions.
对应中文
膨胀纹在评估和治疗方面都提出了相当大的挑战。个体对治疗的反应千变万化，不论反应如何变化，治疗的主要目的是减轻症状、改善外观。目前的治疗和预防方法多样，包括激光治疗、光疗、酸剥治疗、胶原注射、激光脂解、射频技术、微皮肤磨损等但没有一种单一的治疗方法可以完全根除这些病变。
英文原文
The most common method for treating SD is the use of topicals.Only a limited number of topical agents have been evaluated in formal studies for the treatment of SD (such as tretinoin,Trofolastin,Alphastria,cocoa butter,olive oil and silicone gel), although, there are many topical products, available commercially on the market, which claim benefits for prevention and/or treatment of SD, which have not been formally evaluated in any clinical study.
对应中文
治疗SD最常用的方法是外用药物。目前临床上仅有少量外用药物(如维A酸、Trofolastin、Alphastria、可可脂、橄榄油和硅胶等)被评价用于治疗SD。虽然市场上有许多具有商业价值的专题产品，它们声称对SD的预防和/或治疗有好处，但这些产品在任何临床研究中都没有得到正式评价。
英文原文
The use of topical therapies aims to provide lasting improvements in pigmentation and texture of both striae rubrae and albae, with minimal side-effects, in patients of all skin types.However, in order to improve the appearance and reduce the symptoms associated with SD, the following processes should occur; increased collagen production and fibroblastic activity,increase in elasticity and blood perfusion, improvement in cell proliferation, increased skin hydration and anti-inflammatory properties.
对应中文
局部治疗的目的是在所有皮肤类型的患者中，以最小的副作用持续改善红纹和白纹的色素沉着和质地。然而，为了改善外观并减少与SD相关的症状，应进行以下过程：增加胶原生成和成纤维细胞活性，增加弹性和血液灌注，改善细胞增殖，增加皮肤水合作用和抗炎性能。
Discussion
讨论
英文原文
There are a number of topical products used either therapeutically or prophylactically for the management of SD. There are several mechanisms of action reported, (none with level 1 evidence), to be associated with these topical formulations, which include the ability to stimulate collagen production, increase elasticity, improve cell proliferation, anti-inflammatory properties as well as rehydration simultaneously.
对应中文
有许多局部产品用于SD的治疗或预防。据报道，有几种作用机制（无一级证据）与这些外用制剂相关，其中包括刺激胶原蛋白生成、增加弹性、改善细胞增殖、抗炎特性以及同时补液的能力。
英文原文
There is a paucity of a high level of evidence reported in the literature, to support the use of topical products in the prevention of SD. Furthermore, most of the evidence suggests that there is limited proof of the efficacy of the commonly available topical preventative agents.The majority state that the product was clinically proven, however, there were few published clinical trials. The available peer-reviewed literature demonstrated positive results (LOE-2) for some topical treatments, such as Alphastria and Trofolastin, through randomized controlled trials with large sample sizes, although, the type of striae was not stated. Additionally, tretinoin showed varying results across three studies and demonstrated positive results on striae rubrae. One study using Kelo-Cote” silicone gel found some equivocal differences between the placebo and treatment group, however, it was determined that the benefit of this product for SD remains unknown. Two studies using cocoa butter and one study using olive oil demonstrated that there were no significant effects to SD. The majority of topical products did not have any peer-reviewed evidence to support their use on SD. Overall, there is limited evidence for the efficacy of topical therapy for the treatment of SD.
对应中文
文献中报道的支持使用外用产品预防SD的高水平证据很少。此外，大多数证据表明，常见局部预防剂的疗效医学证据有限。大多数证据表明该产品经临床验证，但很少有公开的临床试验。可用的同行评议的文献显示，通过大样本随机对照试验，一些局部治疗，如Alphastria和Trofolastin，取得了积极的结果(LOE-2)，尽管没有说明条纹的类型。此外，维甲酸在三项研究中显示出不同的结果，在红纹上显示阳性结果。一项使用Kelo-Coteâ硅胶的研究发现，安慰剂组和治疗组之间存在一些模棱两可的差异，然而，它被确定该产品对SD的益处仍不清楚。两项使用可可脂的研究和一项使用橄榄油的研究表明，这对SD没有显著影响。大多数外用产品没有任何同行评审的证据来支持它们在SD上的使用。总体而言，局部治疗SD的疗效的证据有限。
英文原文
Although a number of studies showed that some topical products for SD had beneficial outcomes, it was difficult to determine if the results were due to the act of massage. There is limited evi- dence that shows how massage affects the skin, although it is recommended that patients with scars, should massage their scars daily to improve the scar quality.
对应中文
虽然部分研究表明一些外用产品对SD有有益的疗效，但很难确定这些结果是否是由于按摩行为造成的。虽然建议有瘢痕的患者应该每天按摩以改善瘢痕质量，但显示按摩对皮肤有何影响的证据也是有限的。
英文原文
It is evident that different types of SD demonstrate variable degrees of improvement when treated by topical formulations. Some topical treatments are advocated for use on either striae rubrae or striae albae.However, not all topicals are beneficial for use on both types of SD. It is important to identify the pathological effects vs. the symptom relief by these topical products. Patients with striae rubrae require a reduction in pigmentation and erythema, whilst reducing the symptom of itch, which is common in early striae. Conversely, those with striae albae require an increase in pigmentation and may not have symptomatic striae. Therapeutic interventions at the initial stages may minimize structural alterations in the epidermis that occur later. It is important to identify which topical formulation targets which signs and symptoms based on the type of SD and the patient’s Fitzpatrick skin type.A strategic approach could be useful to fully assess a patient in order to create a patient-specific management/treatment plan.A thorough focused, clinical assessment can allow the clinician to tailor the appropriate management strategy to an individual with SD.
对应中文
很明显，不同类型的SD在用外用制剂治疗时表现出不同程度的改善。一些局部治疗被推荐用于红纹或白纹。然而，并不是所有的局部治疗对这两种类型的SD都是有益的。确定这些外用产品的病理效应与缓解症状是很重要的。红纹患者需要减少色素沉着和红斑，同时减少早期红纹常见的炎症症状。相反，那些白斑患者需要增加色素沉着，并且可能没有症状性条纹。初期的治疗干预可以最大限度地减少后来发生的表皮缺损的结构改变。重要的是要根据SD的类型和患者的Fitzpatrick皮肤类型确定哪些局部制剂针对哪些体征和症状。系统性战略方法有助于全面评估患者，以制定针对患者的管理/治疗计划。临床评估可以让临床医生为SD患者量身定制合适的管理策略。
英文原文
In conclusion, there are a limited number of research studies available which investigate the efficacy of different types of topical products used for this common condition. There is no topical formulation, which is most effective in eradicating or improving SD. Furthermore, there is a need for a structure to identify which topical treatments can address the patient’s signs and symptoms and type of SD. Further highquality randomized controlled trials are necessary to assess the efficacy of topical products for the prevention and treatment of SD.
对应中文
总而言之，可用于调查不同类型外用产品对这一常见情况的疗效的研究数量有限。目前还没有最有效根除或改善SD的外用配方。此外，还需要一种结构来确定哪些局部治疗可以解决患者的体征和症状以及SD的类型。需要进一步的高质量随机对照试验来评估外用产品预防和治疗SD的疗效。
REFERENCES
1.Ud-Din S, McGeorge D, Bayat A. Topical management of striae distensae (stretch marks): prevention and therapy of striae rubrae and albae. J Eur Acad Dermatol Venereol. 2016 Feb ; 30 (2) :211-22.