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Based on a presentation by and interview with Joshua L. Fox M.D.
The pulse-dye laser can be used in a standardized manner to reduce the size and discoloration of stretch marks (striae distensae) and increase the elasticity of the skin in most patients. Patients experienced approximately 65% improvement in elasticity and depression of stretch marks after treatment. The Procedure is used on a small test site to determine what influence (amount of power delivered to targeted area over time) to use, and then stretch marks over an entire abdomen or other area can be treated, usually in one sitting, careful patient screening is necessary.
Stretch marks (striae distensae) are common cosmetic skin problem seen after pregnancy, weight gain of when rapid growth spurt cause skin to stretch quickly. This rapid stretching creates irregular marks on the skin that can be shiny, pink, silver, red, or gray and/or indented. In women, stretch marks often occur during pregnancy or weight gain over the abdomen, thighs and breasts. In male body builders, striae can occur over the biceps of other enlarged muscle.
During the American Society of Dermatological Surgery’s 24th Annual Meeting in Boston, Mass., Joshua L. Fox, M.D., indicated that he and Lance A. Barazani, M.D., have evaluated more than 300 patients whose stretch marks were treated with pulse-dye laser. The treatments varied on the amount of fluence used, based on small test treatments done on each patient. Pulse dye laser treatment is known to increase the amount of collagen and elastin in the skin.
Classification System Established
Previously, Dr. Fox Created a classification system for striae based on five components – color surface texture, elasticity of the skin, depression and extent – each of which is graded on a four-point scale, This classification system allows for an objective measurement of striae for both physician and patient that can be repeated after treatment.
Patient Compliance and Expectations
According to Dr. Fox, the most important part of this treatment involves careful selection of patients. Patient evaluation and education is more important in treating striae than for other cosmetic procedures. Patients must have realistic expectations of outcome since striae may need several treatments separated by several weeks to obtain maximal response an they must also be willing to comply with instructions for preparation of the treatment site. Patients must also understand the need for small test site procedure.
Performing a small test on one area of striae is key to success and reduction offside effects, Dr. Fox said. Using a test area helps identify patients who may incur pigment problems and also allow the physician to determine the amount of fluence needed for a given patient. By fine-tuning the amount of fluence, potential for blistering is minimized and has not occurred with treatment.
Patients are instructed to apply alpha-hydroxy acid in concentrations of 8% to 20% or retinoic acid cream to the treatment area for at least 2 weeks prior to the procedure and 3% to 4% hydroquinone for 1 week before the procedure. At the time of the test procedure, the striae are traced onto cleat film similar to the kind used for overhead projectors. The tracing works better than photography for recording striae since striae often for not photograph well, Dr. Fox noted.
The area is then cooled with ice packs or cool gels to reduce tissue damage. During the test procedure, one striae is treated with an increasing fluence on a 10mm spot until there is a purpura or other signs of tissue reaction. During treatment with the laser, the skin is stretched to allow maximal penetration of the striae and the laser hand-piece is held perpendicular to the skin. Pulses are overlapped by about 20%.
The fluence on the test site may range from 1.6 to 3.5. If a 7 mm spot is used, fluence may range from 2.2 to 4.5. Ice packs are applied after the treatment or a tropical lidocaine cream is applied to lessen patient’s discomfort.
The patient then returns 6 weeks after the test treatment for evaluation. Using a clear film, both the patient and physician evaluate how well the treated striae have responded. Once the appropriate fluence is determined, the entire area – the whole abdomen or thigh region – is treated. Fluence may need to be increased on second and third treatment because the skin toughens and does not react as much, he noted.
In the first 118 patients undergoing treatment of striae, there was approximately 65% improvement in elasticity and depression. Patients with darker skin appear to respond slightly better and need fewer treatments. However, there is also a greater risk of pigmentation problems in patients with darker skin and pretreatment with hydroquinone is a necessity.
Certain areas of the body may also respond better than others. “My impression is that the skin on the thighs respond better” Dr Fox noted. This may be due to tauter, better-developed skin on the thighs as compared to that on the abdomen or breasts. There appeared to be no difference in response between skin on men and women.
Treatment of Striae using pulse-dye laser is not a panacea. Some patients may not be satisfied with the color or marks post treatment and erythmea may occasionally last for an extended period. Surface texture of very irregular striae may lessen but may not resolve. The most important point for both physician and patient to understand is that striae will not be completely removed, even after repeated treatments.