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Evaluation of subcision as a treatment for cutaneous striae Journal of Drugs in Dermatology, May-June, 2005 by Pilar Luis-Montoya, Patricia Pichardo-Velazquez, Maria Teresa Hojyo-Tomoka, Judith Dominguez-Cherit

Abstract

Background: Treatment options for cutaneous striae are very limited.

Objective: To determine if subcision is an effective treatment for cutaneous striae and compare a combination with 0.1% tretinoin cream against a single treatment.

Methods: 14 patients were evaluated, each with 3 white striae. One stria received treatment with subcision, one with tretinoin cream in a 0.1% concentration, and one with subcision plus tretinoin. The length of follow-up was 3 months. Two blind investigators evaluated improvement by comparison of the initial and final digital photographs.

Results: Only 7 patients completed 3 months follow-up. A decrease of width and clinical improvement was observed with the 3 treatments. However, some striae showed no change at all and there was no statistically significant difference between treatments. Three patients presented necrosis in striae treated with subcision.

Conclusions: There are no studies in the medical literature about subcision for the treatment of cutaneous striae. This is a preliminary study and considering the undesirable effects of necrosis in a high percentage of striae treated with subcision, the subjective way of evaluation, and the small study group, we can not recommend subcision as a treatment for cutaneous striae. Large studies are necessary to corroborate or to discard our findings.

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Introduction

Microscopic findings support the view that striae are scars. (1) Treatment options for striae are very limited. Improvement has been reported with topical tretinoin, (2) and with the 585-nm pulsed dye laser on striae rubra. (3) Improvement on white striae has been reported with topical 20% glycolic acid combined with 0.05% tretinoin cream or 10% L-ascorbic acid, (4) the 585-nm pulsed dye laser, (5) the 308-nm Excimer Laser, (6) and intense pulsed light. (7) Subcision is a surgical technique introduced in 1995 by Orentreich and Orentreich for the correction of depressed scars (acne, surgical, anetoderma, varicella, depressed skin grafts), depressed contours, cellulite dimples, and wrinkles. (8)

The objectives of this study were to determine if subcision is an effective treatment of cutaneous striae and compare a combination with 0.1% tretinoin cream against a single treatment. Since striae are clinically depressed, it justifies the use of subcision on them. We expected that retinoids would improve mainly the superficial appearance and subcision would elevate the lesions.

Material and Methods

This was a comparative, experimental, prospective, and longitudinal study. Fourteen patients were included. All were healthy females with white cutaneous striae located on the thigh or abdomen, 18 years of age or older without history of keloid scarring, and not on any medication. A written informed consent was signed by each patient. The study was approved by the Human Research Review Committee of the Institution.

In each patient we evaluated 3 striae in a close proximity. A table of random numbers was used to assign each striae to one of the following treatments: 1) subcision (only one time on initial visit), 2) tretinoin topical cream in a 0.1% concentration applied nightly for 3 months, and 3) a combination of subcision plus tretinoin. Digital photographs were taken with the patient in the orthostatic position, and the width of the striae was measured by the same investigator before the treatments and at 3 months follow-up.

Only one dermatologic surgeon performed the subcision based on the description by Orentreich and Orentreich, (8) and the steps followed by Hexsel and Mazzuco. (9) First, the area was cleansed with 70% alcohol. The periphery of striae was marked with ink and then they were anesthetized with 2% lidocaine with epinephrine. Finally, the insertion of a BD Nokor 18G needle at dermal level was made, with subsequent movements made back and forth until a dissection plane was created without resistance.

Two blind investigators compared the initial and final digital photographs to evaluate clinical improvement as follows: excellent (80%), good (70%), regular (50%), poor (30%), and none (0%). The final improvement report was based on an average of the 2 evaluations.

For the statistical analysis we used the Wilcoxon Signed-Rank Test for the paired comparison (before-after) with the same treatment, and the Kruskall-Wallis Test for the comparison between different treatments. A two-tailed p [less than or equal to] .05 was considered statistically significant.

Results

Patients' ages ranged from 21 to 41 years old (mean = 29). Time of evolution of the striae was 1 to 20 years (mean = 7.6). The underlying etiology was pregnancy in 9 patients (64.3%), fast weight changes and growth in 2 patients in each group (14.3%), and obesity in 1 patient (7.1%). Striae width ranged from 2 to 11.3 mm (mean = 5.3 mm).

Only 7 patients completed the 3 months follow-up and were considered for the final evaluation of results (3 striae in every patient = 21 striae). Two of these 7 patients suspended tretinoin because of intolerance. Thus, 7 striae were evaluated for subcision, 5 striae for tretinoin, and 5 striae for subcision plus tretinoin (Table 1). Of the 14 patients treated, 3 (21.4%) presented necrosis (Figure 1) on the striae treated with subcision around 1 week after the procedure.