Treatment of Striae Rubra and Striae Alba With the
585-nm Pulsed-Dye Laser
G LORIA P. J IMÉNEZ , MD, n F RANCISCO F LORES , MD, n B RIAN B ERMAN , MD, P H D, nw
G UNJA -S MITH , P H D w
Department of Dermatology and Cutaneous Surgery, and wDepartment of Medicine, University of Miami School of
n
Medicine, Miami, Florida
BACKGROUND. The treatment of striae distensae has recently
been reported with various lasers such as the 585-nm pulsed dye
laser. At lower fluences (2.0 to 4.0 J/cm2), this laser has been
purported to increase the amount of collagen in the extra-
cellular matrix.
OBJECTIVE. To determine whether the 585-nm pulsed dye laser
is effective in both striae rubra and striae alba after two
treatments and, in addition, to determine whether there is a net
effect on collagen density in treated samples.
METHODS. Twenty patients (skin types II to VI) with either
striae rubra (9) or striae alba (11) were treated at baseline and
at week 6. The total length of the study was 12 weeks.
Untreated striae on the same patient were used as control
subjects. Striae clinical parameters such as color and area were
measured before the first and after the last treatment by an
G. P. JIMÉNEZ, MD, F. FLORES, MD, B. BERMAN, MD, PhD, AND Z. GUNJA-SMITH, PhD HAVE INDICATED NO
SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.
STRETCH MARKS or striae distensae are cosmeti-
cally displeasing to many patients. Clinically, in early
stages, stretch marks are red to pink color (striae
rubra), which over time become increasingly atrophic
and attain a white color (striae alba). Striae occur in
multiple clinical settings such as in adolescent growth
spurts, pregnancy, corticosteroid use, or obesity.1
Although stretch marks are very common, satisfactory
therapeutic intervention has been disappointing.
The treatment of striae distensae or stretch marks
has included many modalities.2–5 Previously, multiple
topical agents have been tried, including tretinoin,
ascorbic acid, and glycolic acid. Topical tretinoin
0.1% was found to improve clinically red severity
scores significantly (graded as mild, moderate, or
severe by the investigator) and length/width
measurements in a controlled study.3 However,
qualitative and quantitative analysis of elastic and
Address correspondence and reprint requests to: Brian Berman, MD,
PhD, Department of Dermatology and Cutaneous Surgery, University of
Miami School of Medicine, 1600 NW 10th Avenue RMSB 2023,
Miami, FL 33136, or e-mail: bberman@med.miami.edu.
r 2003 by the American Society for Dermatologic Surgery, Inc.  Published by Blackwell Publishing, Inc.
ISSN: 1076-0512/02/$15.00/0  Dermatol Surg 2003;29:362–365
AND Z EENAT
independent examiner using a visual analog scale. A hydro-
xyproline assay was used to measure collagen changes in two of
the striae quantitatively.
RESULTS. The 585 nm had a moderate beneficial effect in
reducing the degree of erythema in striae rubra. There was no
apparent clinical change on striae alba. Total collagen per gram
of dry weight of sampled tissue increased in striae treated with
pulsed dye laser versus control subjects.
CONCLUSION. We recommend the use of the 585-nm pulsed
dye laser for striae rubra in patients skin types II to IV. Extreme
caution or avoidance should be observed in pulsed dye laser
treatments for patients with phototypes V to VI even with the
use of low fluences. Tissue collagen changes measured may be
an early change, which precedes significant clinical improve-
ment.
collagen tissue staining intensity did not reveal
significant differences between tretinoin-treated and
vehicle-treated groups.3 Another study used optical
profilometry to measure topographical changes in
striae after treatment with either 0.5% tretinoin
cream, 10% L-ascorbic acid, and 20% glycolic acid.5
However, the sensitivity of profilometry was unable to
detect differences between these treatment groups. The
authors reported improved appearance of striae alba
(based on analysis of 35-mm slides). This study also
used elastin tissue staining to quantitate elastin content
changes.5
Laser therapy has recently gained popularity as a
therapeutic alternative.2–7 The flashlamp-pumped
pulsed dye laser (PDL; 585 nm) has been the most
commonly reported laser used for the treatment of
striae. The rationale for the use of this laser is that the
architecture of the elastic fibers network subjacent to
the dermal–epidermal junction is markedly affected in
skin exhibiting striae.1 Equally reduced and reorga-
nized collagen has been observed.2 Treatment para-
meters have ranged from 7- to 10-mm spot sizes at
fluences ranging from 2.0 to 4.0 J/cm2. Zelickson et al.8
Dermatol Surg 29:4:April 2003 JIMÉNEZ ET AL.: TREATMENT OF STRIAE WITH PULSED DYE LASER
showed histologic proof of superficial dermal band of
well-organized elastin and collagen fibers, with in-
crease cellularity and mucin deposition consisting with
dermal collagen remodeling after PDL treatment for
sun-damaged skin. One controlled study using the
PDL to treat 39 patients with striae reported that a
spot size of 10 mm at a fluence of 3.0 J/cm2 showed the
best improvement in cosmetic appearance. This study
used optical profilometry to assess surface topographic
changes. The study also assessed qualitative elastin
changes with the use of elastic tissue stains. Previous
studies have focused on elastin tissue changes.1–3,5 No
controlled studies to our knowledge have measured
biochemically quantitative collagen changes after laser
treatment. Based on the treatment parameters pre-
viously recommended by McDaniel et al.,2 we studied
the use of the PDL in the treatment of striae distensae
versus untreated control subjects. Quantitative
changes in collagen content were measured biochemi-
cally using a hydroxyproline assay.
Methods
Twenty patients Fitzpatrick skin types II to VI were
enrolled in the study. Treatment striae were randomly
selected from each patient. Control (untreated) striae
from each patient were also selected for control.
Exclusion criteria for enrollment were prior treatment
of striae within the past 4 months of initial PDL
treatment, concomitant systemic steroids, a history of
collagen or elastin disorders, a history of keloids, and
female patients known to be pregnant. Patients ranged
in age from 18 to 45 years of age (average of 28 years).
The duration of treated striae ranged from 6 months
to 20 years (average of 9 years and 4 months). The
cause of the striae treated varied from fast growth
(13 patients), pregnancy (2 patients), weight training
(3 patients), weight loss (1 patient), and unknown
(1 patient) (Table 1).
All of the striae treated were located in either the
abdomen/groin (nine patients), axilla/anterior shoulder
(six patients), or buttocks/upper thigh (five patients).
Table 1. Demographic Data of Patients with Striae Disten-
sae
Fitzpatrick Skin Types Number of Patients Male Female
I appropriate and amino acid standard (L-hydroxypro-
II 5 5
III 3 1 2 analyzed in a spectrophotometer. Quantitated hydro-
IV 9 3 6 xyproline content was then converted to collagen
V 2 2 content using the factor 7.46. Collagen content was
VI 1 1
363
Nine of the treated striae were either pink or red in
color. Ten striae were white in color, and one stria was
light brown in color. Every patient signed an informed
consent that was approved by our institutional review
board. Patients were assessed at baseline (with initial
treatment) and then at weeks 6 (second treatment) and
12. All of the treated striae were treated using 450-ms
585-nm flashlamp-pumped PDL (Cynosure 585 VLS,
Chelmsford, MA) with a 10-mm spot size with 10%
overlap at 3.0 J/cm2. Two of the striae (one stria rubra
and one stria alba) were randomly selected for
collagen biochemical analysis. A 3-mm punch biopsy
was obtained from these two striae and their
corresponding controls at baseline evaluation before
treatment with the PDL and at week 12. Photographs
were also taken of each stria and their corresponding
controls at baseline and week 12. All photographs
were taken with a Polaroid Macro 5SLR (Cambridge,
MA) using identical lighting, patient positioning, and
photographer.
Tracings of the striae borders were made with a
transparent template and a permanent marker. The
striae area was measured using Sigma Scanpro 5.0
software. Subjective measurements of striae color were
recorded at baseline and at week 12 using an analog
scale from 0 to 5: 0, normal; 1, light pink; 2, pink; 3,
light brown; 4, brown; and 5, white.
Hydroxyproline Assay
All biopsy samples (3-mm punch biopsies in normal
saline) were frozen initially at 701C until processed.
All samples were thawed, blotted, and weighed. The
wet weight was recorded, and samples were then
lyophilized in a lyophilizer. The dry weight of all
samples was also recorded. The dry tissue was then
hydrolyzed in constant boiling 6 N HCl (0.5 mL) at
1021C for 19 hours. Hydrolysates were neutralized
with NaOH using methyl red as an indicator, and
aliquots of 10 to 200 mL (total volume of 1.5 mL) were
then assayed for hydroxyproline content. Aliquots
were added to chloramine-T (100 mL) and incubated
for 20 minutes at room temperature. Perchloric acid
3.15 M (100 mL) was then added, and the solution was
further incubated for 5 minutes at room temperature;
20% p-Dimethylaminobenzaldehyde (100 mL) was
added this solution, which was incubated for 20
minutes in a 601C water bath. Samples were then
cooled at room temperature, and all unknown samples
line, 10 mg dissolved in 100 mL 0.001 M HCl) were
then based on a gram of dry weight of tissue.
364 JIMÉNEZ ET AL.: TREATMENT OF STRIAE WITH PULSED DYE LASER Dermatol Surg 29:4:April 2003

Results N=20 / p=0.21

Thirteen of 20 patients had a net decrease in area of 70

% Percentage of
treatment striae. However, 9 of 20 control or 69 Untreated

of striae area
improvement
untreated striae also had a net decrease in striae area. 68
67 Treated with
There was no significant difference (P 5 0.21) between 66 the PDL
control and treatment striae at week 12 (end 65
of the study) (Figure 1). Two random control and 64
wk 12
treatment striae (one striae rubra and one striae
Figure 1. Net percentage of improvement of striae-treated area
alba) from the 20 total patients were biopsied and versus control at 12 weeks.
assayed for collagen content. Both of these treatment
striae had a net increase in collagen content, whereas
both control striae had a net decrease in collagen
content at 12 weeks (Figures 2 and 3). These
two treatment striae also had a net decrease in area
after treatment with PDL. One additional patient 400
(skin type VI) whose treatment and control striae

µg collagen/dry
weight tissue
300 Untreated
were biopsied at baseline refused biopsies at 12
200 Treated with the
weeks because of persistent hyperpigmentation at 12 PDL
weeks on the treated striae. Nine of the 20 treatment 100
striae were considered striae rubra (light pink 0
wk 0 wk 12
to red color). The remaining striae were striae alba
(10) and a light brown striae. After two treatments Figure 2. Collagen content before and after treatment with PDL
with the PDL, 4 the 20 striae had a change in color. All (striae rubra).
of the striae with a change in color after treatment
were considered striae rubra. Only one of these striae
had an apparent complete response with a change in
color almost identical to surrounding normal skin
(skin type II). None of the striae alba had a change in
color (Table 2). No significant differences in improve-
300
ment were observed related to the anatomical location
µg collagen/dry

250 Untreated
weight tissue

and age. 200

150 Treated with
100 the PDL
50
Discussion 0
wk 0 wk 12
The treatment of striae distensae remains very difficult. Figure 3. Collagen content before and after treatment with the PDL
Controlled studies reporting on previously tried (striae alba).

Table 2. Striae Color at Baseline and After Treatment

Striae Rubra (N 5 9) Striae Alba (N 5 10) Light Brown (N 5 1)

Before After Before After Before After

Light Pink Normal mm White Brown kk Light Brown 5

Light Pink 5 White 5
Light Pink 5 White 5
Pink Light Pink m White 5
Pink Light Pink m White 5
Pink Light Pink m White 5
Pink 5 White 5
Pink 5 White 5
Red Pink m White 5
White 5
mImprovement; kWorse; 5 no change.
Dermatol Surg 29:4:April 2003 JIMÉNEZ ET AL.: TREATMENT OF STRIAE WITH PULSED DYE LASER
modalities remain scant. Even with the lack of
chromometric analysis, the limited number of patients,
and the limited follow-up, our study did not reveal a
dramatic difference in striae appearance after two
treatments with the PDL. Only striae that were pink to
red in color showed improvement (four of nine with
only one patient achieving complete resolution). White
striae fared worse, with no visible change in color after
the treatment. These results do not reflect previous
experience with striae alba.3 There was one patient
(skin type VI) with postinflammatory hyperpigmenta-
tion after the PDL treatment. All patients in this study
had skin photo types II to VI. This is important
because melanin competes as a chromophore with
hemoglobin for the light energy from the 585-nm PDL.
In a previous study in which the 585-nm PDL was used
to treat stretch marks in patients with increased
melanin (skin types IV to VI), laser treatment resulted
in postinflammatory hyperpigmentation. Thus, 585-
nm PDL scar treatment should be approached with
caution in the melanin-rich skin types of IV to VI until
more data are available.4,9 In our experience, striae
color is by far the most concerning feature to a patient.
There was also no significant difference in striae area
between control and treatment striae. The measure-
ment of collagen content from the two biopsied
patients did show evidence of increase collagen
amount after treatment with the PDL, matching the
histologic findings of Zelickson at el.8 after PDL
treatment for sun-damaged skin. However, this is a
limited sample size, and statistical significance cannot
be drawn. A previous study reported on the increased
amounts of glycosaminoglycan matrix in striae com-
pared with normal skin, with a relative paucity of
elastin and collagen density.1 It is possible that the
increased collagen after laser treatment is an early
phenomenon, with clinical parameters such as striae
color and surface area changes lagging behind these
tissue changes. These increase in collagen per gram of
365
dry weight observed could be a result of a nonspecific
effect of trauma on the stretch marks unrelated to any
specific laser effect. Perhaps clinical follow-up in laser-
treated patients should extend beyond 12 weeks, as
other authors have reported favorable changes with
prolonged follow-up. We conclude that treatment of
striae distensae with the PDL should be reserved to
striae with some degree of pink to red color. Caution
should be used on darker skin types, and laser
treatment should be avoided as possible in skin types
VI even at low fluences.4
Further studies with prolonged follow-up should
focus on the relationship between collagen as well as
other extracellular matrix components’ changes and
clinical parameter changes after PDL treatment.
References
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