Patient Presentation
A 10-year-old female came to clinic because of a rash. The mother said that she had noted it about 6 weeks previously but it was not going away and it was spreading. She denied any new soaps, lotions, detergents or hygiene products including insect repellent or sunscreen. It was occasionally itchy but overall the child hadn’t noticed it. The family history was positive for diabetes mellitus type II, hyperlipidemia and heart disease. The review of systems was negative.
The pertinent physical exam showed an obese female with normal vital signs. Her weight had increased over the last year from 43.1 kg (95%) to 60.2 kg (95% for an 11.5 year old). Her length had increased the normal 5 cm over the past year and was at the 75%. Her skin showed several parallel linear lesions on her abdomen, buttocks and upper legs. Some were pink-red (legs and buttocks) and others were mixed with both reddened lesions and some that were whiter on the abdomen. She had no other skin findings. She was Tanner 1 for breast and public hair. The rest of her examination was normal.
The diagnosis of striae was made. The mother herself noted that she had striae mainly from when she was pregnant. She was very upset that her daughter had striae and wanted a referral to dermatology immediately. The pediatrician discussed the natural history of striae and said that since this was considered a normal process he would send the consultation but it was unlikely that the appointment would happen immediately. He also discussed her overall weight increase and recommended to have screening labs for obesity and hyperlipidemia completed. “We did those a year ago but she had gained a lot of weight since then. Given your family history I think it would be important to do,” he said. “Let’s talk some more about her lifestyle and her food and exercise and see how we can improve the weight gain, and maybe help to decrease the stretch marks,” he remarked.
The patient’s clinical course at followup 3 months later showed that the dermatology appointment was scheduled in another 3 months. Her initial laboratory testing was normal but her glucose and hemoglobin A1c were elevated compared to previous year. She was still gaining weight at the same rate, and additional counseling was given.
Discussion
Stretch marks or striae distensae (SD) are dermal scars which form linear, atrophic lesions, usually in parallel, that occur due to changes in connective tissue. They have an initial pink/red/purple stage (striae rubrae and have inflammation occurring) and then turn a paler color and more wrinkled (striae albae, where there is atrophy). They are associated with growth spurts, pregnancy, obesity and excess steroids. The specific mechanisms are unknown but it is believed to be due to a disruption of the collagen fibrils and elastic fibers within the skin. Basically the collagen fibrils usually line up in parallel and provide structural support to the skin while elastic fibers allow stretching of the skin. Collagen fibrils are disrupted providing less structure, and the disrupted area is filled by newly synthesized collagen. Elastin fibers are also disrupted and are not able to form their normal structure.
SD are caused by traction on the skin especially in times of rapid growth such as linear growth in puberty, pregnancy, or weight gain. Genetic factors do play a part. SD is considered a normal process. However the lesions can be quite disfiguring and cause emotional distress.
Treatment options can include enhanced collagen production, decreasing vascularity and increasing melanin production. Various laser treatments are likely overall the most effective. Radiofrequency, microdermabrasion and needling can also be used. Treatment is most effective during the striae rubra stage.
Learning Point
SD occur in approximately 50- 90% of women. In adolescence the reported prevalence is 6 to 86%. Females more commonly have striae on the calves, thighs, and buttocks whereas males have them on the lower back, knees, and buttocks. Physiologic striate which occurred during the adolescent growth spurt often become less conspicuous with time and have excellent prognosis when compared to other forms of striae.
In one study the most common dermatosis in overweight and obese children, and with those with increased insulin were keratosis pilaris, SD, hyperhidrosis, acanthosis nigricans, and plantar hyperkeratosis. They also found that the darker toned skin the individual had, the more likely they had acanthosis nigricans or keratosis pilaris.
Questions for Further Discussion
1. What are treatment options for scars and keloids?
2. What prevention options are there for SD?
3. What does acanthosis nigricans appear like and what is the typical location?
Related Cases
- Disease: Striae Distensae | Skin Diseases | Scars
- Symptom/Presentation: Rash
- Specialty: Dermatology
- Age:School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Skin Conditions and Scars.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Schuck DC, de Carvalho CM, Sousa MPJ, et al. Unraveling the molecular and cellular mechanisms of stretch marks. J Cosmet Dermatol. 2020;19(1):190-198. doi:10.1111/jocd.12974
Elsedfy H. Striae distensae in adolescents: A mini review. Acta Bio Medica Atenei Parmensis. 2020;91(1):176-181. doi:10.23750/abm.v91i1.9248
Kus MM, Mulayim MK, Kus C, et al. Dermatoses in overweight and obese children and their relationship with insulin and skin color. Journal of Cosmetic Dermatology. 2023;22(10):2791-2798. doi:10.1111/jocd.15773
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa