Striae Gravidarum: More than a 'Nuisance,' Say Researchers

Kate Johnson

November 11, 2021

Striae gravidarum (SG) ― or pregnancy stretch marks ― are a source of distress and embarrassment for many women, similar in that respect to acne, psoriasis, or eczema, according to a new study.

In the study of healthy pregnant women, "we found that SG can be associated with a host of negative reactions reflecting increased psychological and emotional distress," report Kaveri Karhade, MD, from the Berman Skin Institute, Los Altos, California, and her co-authors from the University of Michigan Medical School, Ann Arbor. Karhade was with the Department of Dermatology at the University of Michigan at the time the study was conducted.

"We suggest that healthcare providers should avoid thinking of SG as merely a cosmetic 'nuisance,' " they write in an article published in the International Journal of Women's Dermatology. "Instead, it would be reasonable for providers to approach SG like other dermatologic concerns, and to consider asking patients whether SG cause emotional distress and whether prevention or treatment strategies should be attempted, even if not completely effective and potentially costly," they write.

The investigators did not evaluate treatments, but Frank Wang, MD, senior author of the study and professor of clinical dermatology at the University of Michigan Medicine, told Medscape Medical News that "while they aren't completely effective, some treatments can still help." In addition, "recommending something also shows that you are listening to patients' concerns ― taking their concerns and skin lesions seriously," he said.

Patient Survey

The authors conducted a cross-sectional survey of 116 healthy pregnant women with SG. Participants were asked about the emotional and psychological effects of the lesions and how SG affects quality of life. The survey was modeled on questions from the Dermatology Life Quality Index (DLQI), which asks about the impact of skin disease on embarrassment/self-consciousness, clothing choice, leisure activities, and interpersonal problems. "Content of questions was also devised from direct discussion with pregnant women attending clinic appointments or participating in other research studies on SG at our institution, and discussion with expert colleagues in obstetrics and dermatology," the authors explain.

The survey consisted of 35 questions concerning demographics, pregnancy characteristics, personal and family history of SG, specific physical concerns about SG, impact of SG on attitude toward pregnancy, willingness to prevent SG or seek treatment, severity of SG (self-evaluated), the impact of SG on specific life-quality facets, and the location of lesions.

About two thirds of respondents were aged 25 to 36 years and were White; the remainder self-identified as Asian, Black, Native American, or "other." Most women reported "average" weight gain during the current pregnancy. Almost half of participants (45%) reporting a history of SG from prior pregnancies, and 65% reported a family history of SG.

The abdomen was identified most frequently as the location of SG (75%), followed by the breasts (43%), hips (43%), thighs (36%), buttocks (19%), and other areas (6%).

For most women (75%), permanency of the lesions was their top concern. About half (51%) reported that they had attempted to prevent SG, mostly with topical creams or oils. Three quarters (75%) expressed interest in seeking treatment for SG, but this percentage dropped significantly to 33% (P =.008) if that treatment would not be covered by insurance.

Regarding the psychological impact of SG, embarrassment/self-consciousness correlated most strongly with lesion severity, followed by general quality of life, impact on choice of attire, impact on self-image/self-esteem, feelings of anxiety/depression related to SG, alteration of social/leisure activities related to SG (all P < .0001), and creation of interpersonal problems related to SG (P = .02).

The investigators also found that an increase in the effect of SG on self-image/self-esteem was "moderately associated" with younger age (P < .001) and that increased embarrassment related to SG was "moderately associated" with weight gain during pregnancy (P < .001).

"For years, stretch marks have been a topic to avoid and something many women try to hide," Timothy Johnson, MD, professor of obstetrics and gynecology at the University of Michigan and co-author of the study, said in a press release from the university. "Pregnant women talk about stretch marks with me every single week at clinic, and it's time we break the stigma and start talking about them openly with all patients.... By doing this study, we have an opportunity to normalize stretch marks in the context of all other dermatological conditions."

Asked to comment on the findings, Tina Alster, MD, director of the Washington Institute of Dermatologic Laser Surgery and clinical professor of dermatology at Georgetown University, Washington, DC, said her three decades of clinical experience support the authors' findings. "Most patients who have striae are very self-conscious about them and report that their presence has negatively impacted their quality of life and self-confidence," she told Medscape. "Of course, patients who come to my office are interested in having them treated, so my patient subset is skewed," she added.

She said treatment strategies that she discusses with patients include topical retinol/retinoids, which she said provide "low clinical response"; microneedling, which provides "marked" clinical response; and nonablative laser treatment, which provides "good" clinical response.

Considering particular patient characteristics, including budget, Alster said, "For those on a limited budget, I would propose daily use of a topical retinol, despite the low clinical effect. Many retinol-containing products are available over the counter. Prescription-strength retinoic acid tends to be pricey, often costing as much as in-office treatments." Medical microneedling (not the cosmetic "roller" microneedling performed by aestheticians), she added, "gives the best results for the money and produces clinical results that mirror those achieved with lasers."

Wang agreed that even recommending less expensive and less efficacious options such as over-the-counter creams can help alleviate patients' concerns. "It shows that you are being holistic ― not just caring for medical issues around pregnancy, but that you also take the emotional/psychological concerns of pregnant individuals and new parents seriously and that you recognize the impact of skin problems on quality of life. In the end, recommending something ― in other words, providing some options, like creams or other therapies, for instance ― is still, in my opinion, better than not recommending anything."

Wang is involved with a study that is currently enrolling patients and that is evaluating the formation of early SG, which includes performing skin biopsies as soon as lesions appear.

The study had no funding. The study authors and Alster have disclosed no relevant financial relationships.

Int J Womens Dermatol. Published online November 3, 2021. Full text

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