Systematic Treatment for Striae Helps Physicians Meet Patient Goals
When cosmetic surgeons have a system in place for evaluating striae along selected criteria, they can establish more realistic goals and increase patient satisfaction, said Joshua L. Fox, M.D.
He uses a system that includes the following steps: 1) preoperative evaluation of striae; 2) patient education and agreement by patient and physician of the treatment and desired outcome; 3) the use of a test site to determine the patient’s response to laser treatment and the proper laser settings for the patient; 4) pre- and postlaser therapy topical treatments; 5) two to three laser treatment sessions; and 6) follow-up to evaluate the treatment’s success.
“We’re getting better results now than we used to get before with just the laser alone [without pre- and postlaser topical treatments],” said Dr. Fox, a practicing dermatologic surgeon and medical director for the Center for Laser and Cosmetic Surgery, an affiliate of Long Island Jewish Medical Center. “Over 80% of the 118 patients studied were very happy with the system and with the results. We still see a need for improvement.”
Referring to a recent study of the system’s efficacy, Dr. Fox and colleagues observed a 50% improvement in skin color and a 65% improvement in skin elasticity. The study included 110 women and eight men with primarily mature striae. The patients had a wide range of ages and skin types. Assessing Striae Dr. Fox said there are five criteria by which he and his colleagues assess striae before and after treatment: color, elasticity, depression of striae, surface changes, and extent of striae. He noted that evaluating striae by these criteria facilitates the setting of treatment goals and evaluating the striae’s response to treatment.
“Previously, people were just saying, “Do the striae look better or worse?” Dr. Fox said. “What does that mean, Better or worse?” Some striae are markedly depressed; some of them are basically flat with only color changes. Some of them are the same skin color, but depressed. They vary in the amount of normal recoil that has been lost.
“We developed this system so that patients could better reproducibly define which aspects of the striae were bothering them,” he continued. “Then observers, both physicians and patients alike, could better reproducibly define how the treatment improved the appearance, based on each of these criteria.”
In the first step of the system, the physician evaluates the patient. Dr. Fox said the physician needs to know whether the patient is an appropriate candidate with realistic expectations, and whether that person will be able to follow pre- and post-treatment regimens. Women who are pregnant or are expecting to become pregnant, are not appropriate candidates, for example, he said.
The physician also will need to obtain a thorough medical history to determine whether the patient is a good candidate for laser treatment of striae, according to Dr. Fox. Contraindications would include any bleeding disorder, as well as the tendency to form keloids or to develop post-inflammatory hypo-or hyperpigmentation. “If you don’t have the appropriate population, you’re not going to get the appropriate results,” said Dr. Fox.
After evaluating the patient, the physician prepares the patient’s skin with a topical preparation such as alpha-hydroxy acid, tretinoin (Retin-A), or hydroquinones. The hydroquinones are particularly useful in type III skin and darker, he said. It helps prevent postinflammatory pigmentation-particularly in people with darker skin, who are more susceptible to this problem.
Third, the physician treats a test site with pulsed dye laser therapy to determine which fluences are the most effective for the individual patient, he said. Dr. Fox and colleagues used a pulsed dye laser (Cynosure), which has a wavelength of 585 nm and a 486 µ s pulse.
“By defining the appropriate fluence, you’re able to avoid the risk of getting blistering across an entire treatment area or of discoloring an entire treatment area,” said Dr. Fox. “We use three to five fluences on a test site to see which one is maximal for that patient. The fluence that achieves the best results on the test site is the one that we will subsequently use for the entire treatment area.”
When treating the test site, Dr. Fox and colleagues frequently use a 10-mm spot size and fluences ranging between 1.6 J/cm2 and 3.6 J/cm2 . With a 7-mm spot size the fluences are higher. He noted that the maximal fluence for most patients ranges between 2.5 J/cm2 and 3.0 J/cm2. He and his colleagues use clear sheets over the test site for the evaluation. After determining the optimal fluence for the patient, the physician treats the entire area. After each session, the area is treated with one of the topical therapies used in pretreatment, as well as ice, EMLA, or cooling gel, he said. Treatment is completed in two to three sessions.
Dr. Fox’s study showed that this system reduces the risk of adverse sequelae. “When [we use] just the laser alone without a topical preparation, a test site, or topical post-treatment, we increase the risk of postinflammatory hyperpigmentation,” he commented.
“This system improves the reproductibility of treating striae,” said Dr. Fox. “You get consistently better outcomes with less adverse sequelae. The pre- and post-treatment topical therapies lessen the risk of scarring, discoloration, or blistering. The patient education and involvement, as well as the individualized therapy devised through the use of test sites, add to patient’s satisfaction.” Dr. Fox has no financial interest in Cynosure or its products.