Biophysical properties of striae rubra and striae alba in human skin: Comparison with normal skin.

BACKGROUND: Striae distensae are common dermal lesions that progress through two different stages: the striae rubra, which appears to be erythematous, and striae alba, which is characterized by a hypopigmented feature. The clinical characteristics between striae distensae stages and normal skin remain unknown. OBJECTIVES: We aimed to investigate the clinical characteristics according to stages of striae distensae in terms of their biophysical properties, using objective noninvasive measurements in comparison with adjacent normal skin. METHODS: Sixty-one healthy female subjects with striae distensae were included as follows: 30 with striae rubra and 31 with striae alba on the abdomen and thighs. Hydration of the epidermis and dermis, skin color brightness, and Erythema index were measured. Skin elasticity, roughness, and dermal echo-density of the skin with striae distensae and adjacent normal skin were also measured. RESULTS: Hydration of the epidermis and dermis showed no significant difference between the skin with striae distensae and normal skin. Brightness of skin with striae alba and normal skin was significantly higher than that of skin with striae rubra. Erythema index of skin with striae rubra was significantly higher than that of skin with striae alba and normal skin. Skin with striae rubra and striae alba had a rougher surface than normal skin. Elasticity and dermal echo-density were significantly lower in striae distensae skin. CONCLUSIONS: Striae rubra and striae alba had similar biophysical properties in terms of skin hydration, elasticity, roughness, and dermal density. Moreover, striae distensae have less elasticity, more roughness, and lower dermal density than normal skin.

Efficacy of striae gravidarum extension and localization on predicting intraperitoneal adhesion risk.

AIM: To evaluate the diagnostic value of striae gravidarum (SG) presence and localization in predicting the intraperitoneal adhesion (IPA) risk in pregnant women with a history of at least one previous cesarean delivery (CD). METHODS: A total of 100 pregnant women with repeated CD were included in this prospective observational study. Patients were divided into three groups according to severity of SG with Davey scoring system. Intraoperative adhesion severity and extension were evaluated by using Nair classification system. Moreover, operation duration and neonatal outcomes were analyzed. RESULTS: Demographic features were comparable between the groups. Adhesion scores were significantly higher in mild and severe SG groups (for mild SG: 1.93 ± 0.99, for severe SG: 2.81 ± 0.88 and for no SG: 1.4 ± 0.57; P < 0.001). Analysis revealed a positive correlation between IPA and severity of SG (P < 0.001). There was a correlation between increased striae density and adhesion severity especially in the right and left upper quadrants of the abdomen (for right quadrant: r = 0.515, P < 0.001; for left quadrant: r = 0.359, P = 0.005). CONCLUSION: Our results suggest that preoperative evaluation of SG severity and extend particularly in upper quadrants is a feasible option to predict IPA risk in patients with repeated CD.

Clinical characteristics of women with familial pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: Understanding the clustering of pelvic floor disorders (PFDs) within families is important because it may suggest underlying risk factors that may be environmental, genetic or both. The objective of this study was to describe clinical characteristics observed in familial cases with PFDs and compare them with strictly defined controls. METHODS: Women evaluated and treated for PFDs were recruited as part of a larger genetic study. Here, we define familial cases as those with bothersome symptoms or treatment for a PFD (pelvic organ prolapse [POP], stress urinary incontinence [SUI], and overactive bladder [OAB]) and who had a first-degree relative with bothersome symptoms or treatment for the same pelvic floor defect. We assigned clinical characteristics to probands and their relatives using standardized symptom questions (PFDI), examination, and review of treatment records, if any. RESULTS: We identified 126 familial POP cases, 183 familial SUI cases, and 101 familial OAB cases. Familial cases were more likely to have bothersome symptoms for more than one PFD. Among familial POP cases, bothersome SUI (71 %), OAB (54 %), and a combination of all three disorders (48 %) were common. Among familial SUI cases, bothersome OAB (60 %), POP (59 %), and combinations of all disorders (40 %) were common. Among familial OAB cases, bothersome SUI (88 %), POP (66 %), and combinations of all three disorders (59 %) were common. CONCLUSIONS: Familial cases of POP, SUI, and OAB are more likely to have more than one pelvic floor defect. It is likely that underlying genetic factors contribute to more than one pelvic floor defect.

Striae: a potential precipitating factor for Koebner phenomenon in psoriasis?

The Koebner phenomenon (isomorphic response) is defined as the development of typical lesions of a dermatosis that occur in areas of trauma in previously uninvolved skin. Rare reports have suggested that striae are a form of injury to the skin that can result in koebnerization of psoriasis, vitiligo, and lichen planus. We herein report a 27-year-old female patient with plaque psoriasis who developed psoriatic lesions along striae distensae.

Evaluating the efficacy of microneedling technique in treating striae alba lesions.

Striae alba, as an unsettling skin complication, has the potential to threaten the physical appearance and psychological health of individuals. So far, dermatologists' endeavors have been futile in finding an ideal treatment. This study evaluated microneedling as a novel treatment modality for striae alba scars. Microneedling was implemented in 1-3 sessions in 2-week intervals among patients with striae alba lesions. The lesions were photographed before and 3 months after the treatment, while all side effects were recorded. Two non-involved dermatologists and a patient self-report based on a visual analog score scale were utilized to evaluate the clinical improvement of striae scars. The complication rate among the 32 patients was 25%, which consisted of seven (21.9%) cases of post-inflammatory hyperpigmentation and one case (3.1%) of skin infection. The average improvement score among the patients in our study based on their self-report was 5.3 ± 1.3. (Range 4-8), while based on physician evaluation was 5.6 ± 1.2 (range 3.5-8). There was a significant association between lower age and higher self-report scores. Also, the improvement of lesions was more significant in skin type 3 compared to 2, based on physician assessment. In this study, MN was effective in ameliorating SA scars and was observed to induce better clinical satisfaction in younger patients and breast lesions. The studies concerning the use of MN in treating SA have yielded much attention lately, and they have denoted the relatively low cost of MN, its capability to be utilized over vast treatment areas, and its safety in that regard. Further research regarding the comparison of MN's efficacy in solo use versus implementing it as an adjuvant modality should be carried out.

The neglected secret: Association of abdominal striae with stress urinary incontinence in primigravid pregnant women.

OBJECTIVE(S): To compare the presence and severity of striae gravidarum in pregnant women with and without stress urinary incontinence and to evaluate whether there is a relationship between the severity of striae gravidarum and the severity of incontinence in pregnant women with stress urinary incontinence. STUDY DESIGN: Healthy primigravid pregnant women with an uneventful singleton pregnancy at 36-37 weeks of gestation were included. All women were asked two questions to assess the presence of urinary incontinence. Women who answered 'yes' to the question 'Do you have any involuntary urinary leakage during coughing/laughing/sneezing/running/jumping?' and 'no' to the question 'Do you have any involuntary urinary leakage accompanied by a strong urge to void?' were classified as women with stress urinary incontinence, and women who answered 'no' to both questions were classified as women without stress urinary incontinence. The presence and severity of striae gravidarum of these two groups were evaluated with the Davey score, and the severity of incontinence of women with stress urinary incontinence was evaluated with the Incontinence severity index questionnaire. RESULTS: The Davey score of pregnant women with stress urinary incontinence was significantly higher than the score of women without stress urinary incontinence and the presence of severe striae gravidarum was more common in women with stress urinary incontinence. There was a positive, significant correlation between Incontinence severity index and Davey scores in women with stress urinary incontinence, and this was the only independent correlation that was significant in linear regression analysis. CONCLUSION(S): Presence and severity of striae gravidarum is correlated with the presence and severity of stress urinary incontinence in primigravid pregnant women. Evaluation of striae gravidarum may be useful in predicting the development of stress urinary incontinence and taking necessary precautions against it. This issue should be evaluated with good quality studies.

A case-control study of cutaneous signs in adult patients with Marfan disease: diagnostic value of striae.

BACKGROUND: Marfan syndrome (MS) (OMIM 154700) has been associated with various skin manifestations. OBJECTIVE: We sought to clarify the value of skin signs in patients with MS. METHODS: This was a case-control study. A total of 61 consecutive patients (median age: 34 years) seen in the French Reference Centre for MS and Related Disorders and with a confirmed diagnosis of MS were paired with 61 age-, sex-, and height-paired control subjects. All had a structured interview and standardized dermatologic examination. The gold standard for MS diagnosis was the Ghent criteria. RESULTS: Striae of any type were significantly (P = .0001) more frequent in patients with MS (92%) than in control subjects (61%), but specificity was low (39%, 95% confidence interval [CI] 27-52). Striae on unusual locations (other than buttock, hip, or thigh) were more frequent in patients with MS (66%) than in control subjects (16%) (P < .0001). This finding had a high specificity (84%, 95% CI 74-93), without notably decreasing sensitivity (66%, 95% CI 54-77). Hypertrophic, large, or atrophic surgical or posttraumatic, frequently hypopigmented or hyperpigmented, scars were present in 46% of patients with MS and 21% of control subjects (P = .007). Sensitivity was 46% (95% CI 34-58) and specificity 79% (95% CI 67-87). Atypical striae in some control subjects could be attributed to intensive practice of sports. LIMITATION: A few control subjects were selected from patients consulting the MS center but without a diagnosis of MS. CONCLUSION: Striae are a good diagnostic criterion for MS, particularly when arising in unusual sites. Other reported skin signs of MS are infrequent.

Lichen Sclerosus on the Sites of Striae Distensae and a Surgical Scar in a Patient with Coexistent Morphea.

Lichen sclerosus (LS), also known as lichen sclerosus et atrophicus, is a chronic inflammatory mucocutaneous disease affecting the genital and/or extragenital areas. Although LS usually occurs alone, its coexistence in morphea patients has been reported in 5.7% and 38.0% (genital LS) of cases, in two series (1). A 74-year-old woman presented with a 6-month history of multiple asymptomatic, shiny , indurated, brownish large flat plaques located on the abdomen (Figure 1, a-b) and back, intermingled with slightly atrophic, white-colored, guttate, and patchy areas (Figure 1, d-e). Both punch biopsies of the sclerotic plaques on the back and abdomen showed findings consistent with morphea (Figure 1, c, f). Furthermore, the punch biopsy of a well-demarcated white plaque on the back revealed findings compatible with LS (Figure 1, f). Remarkably, there were also multiple white-colored lesions on the sites of pregnancy-induced striae distensae (SD) (Figure 2, a-b) on the lower abdomen and an old appendectomy scar (Figure 2, c). There was no anogenital involvement. A diagnosis of morphea-LS overlap was established and white lesions located on the surgical scar and SD were clinically evaluated as LS. Methotrexate (15 mg/week) achieved a partial regression of morphea plaques in three months. However, white LS lesions remained unchanged. Our patient presented with coexistence of LS and morphea on different sites of the trunk and on the same lesion. Additionally, one of the isolated LS lesions was located on a surgical scar. Occurrence of LS on skin grafts, irradiated areas, injection sites, or burn/surgical scars has been attributed to the Koebner phenomenon, also called isomorphic response, defined as "the formation of the skin lesions in the same morphology of the existing disease on the areas of various cutaneous injuries" (2). LS is classified under the Koebner category-III (occasional lesions) (2). However, in a case of morphea with features of LS that developed in 1 month following a herpes zoster infection has been suggested to represent "Wolf's isotopic response" (3), which was originally defined as "the occurrence of a new skin disease at the site of another, unrelated and already healed skin disorder" with a time interval between the first and second diseases ranging from months to several years (4). Remarkably, typical morphea plaques in our patient did not involve the surgical scar, in contrast to a cohort in which 16% of 329 patients developed initial morphea lesions at sites of prior (surgery) or ongoing/repetitive (chronic friction) skin trauma (5). SD appear on skin as atrophic linear bands mostly due to rapid weight changes, pregnancy, Cushing syndrome, or prolonged use of corticosteroids (6). The mechanism underlying the occurrence of several diseases on striae is still elusive. Blunt trauma occurring during the development of striae has been suggested to cause the Koebner phenomenon in patients with vitiligo, psoriasis, and lichen planus (7), but it has been suggested that the occurrence of leukemia cutis on SD in a patient reflects Wolf's isotopic response (8). Although chronic graft-versus-host disease, urticarial vasculitis, keloid, lupus erythematosus, diffuse normolipemic plane xanthoma, and drug-induced cutaneous eruptions have been reported to occur on striae (6,9), such an association with LS as in our patient has not been previously documented in the literature. Concomitant occurrence of LS patches on different previous lesions such as a surgical scar and SD in our patient raises the possibility of a common underlying mechanism. As mentioned above, the terms "Koebner phenomenon" or "Wolf's isotopic response" have been used to designate the development of some diseases in injured areas. However, Happle and Kluger (10) claimed in a recent statement that "there is no clear-cut criterion to distinguish isotopic response from Koebner phenomenon and all reactions of this kind represent examples of Koebner phenomenon", which seems to be the best way to describe the site-specific occurrence of LS lesions in our patient.

Hidden association between the presence and severity of striae gravidarum and low back pain in pregnancy.

OBJECTIVE(S): To investigate the association between striae gravidarum and low back pain in pregnancy. STUDY DESIGN: 200 healthy pregnant women with first, uncomplicated and singleton pregnancy at a gestation age of 36-37 weeks were evaluated for striae gravidarum Davey score. Back pain was assessed by Visual Analogue Scale and functional disability by the Turkish version of Oswestry Disability Index. RESULTS: 118 (59%) had low back pain. The Davey score was higher in women with low back pain (6.6 ± 2.2 vs. 4.4 ± 2.1; p < 0.001). Davey score and total Oswestry Disability Index score were positively correlated with Visual Analogue Scale in women with low back pain (r = 0.570, p < 0.001 and r = 0.329, p < 0.001, respectively). There were also significant positive correlations between Davey scores and Oswestry Disability Index scores of each different situation (pain intensity, personal care and lifting, walking, sitting, standing, sleeping, sexual life, social life and travelling). CONCLUSION: Presence and severity of low back pain is correlated with the presence and severity of striae gravidarum in pregnant women. Therefore, the presence of low back pain can be predicted by simple striae gravidarum evaluation and follow-up. So, necessary precautions can be recommended to prevent pain and functional limitations that can occur during pregnancy.

Association between severities of striae gravidarum and Obstetric Anal Sphincter Injuries (OASIS).

OBJECTIVES: to examine the association between the severities of Striae Gravidarum (SG) and Obstetric Anal Sphincter Injuries (OASIS) and to measure the symptoms regarding urinary incontinence, fecal/flatus incontinence, and dyspareunia, at 6 and 12 months postpartum. DESIGN: this is a cohort study. SETTING: four university teaching medical centers in Israel, two in the north and two in the center of the country. PARTICIPANTS: women with OASIS were interviewed and assessed for SG. OASIS was divided into 4 groups: 3A, 3B, 3C and 4. Inclusion criteria were:OASIS diagnosis, non-instrumental vaginal childbirth, birth between 37 and 42 gestational weeks, singleton newborn, neonatal birth weight of Severity scoring of SG severity scoring, using Atwal's Numerical Scoring System,observed 4 body sites; Abdomen, Breasts, Hips, and Buttocks., Total severity score (TSS) for all sites range between 0 and 24 and categorized: 0-3: no SG (NSG) and 4 and over: SG. The Pelvic Floor Symptom Bother Questionnaire (PFBQ),a validated, structured questionnaire, was used for the 6 and 12 month follow-up assessments, with nine items regarding pelvic floor dysfunction (urinary and bowel impairment uterine prolapse and sexual function). MEASUREMENTS AND FINDINGS: eighty women who had OASIS were enlisted, interviewed and assessed for SG. The average score for women with some SG was 6.10 (SD = 4.12). There were 58 (72.5%) women with OASIS level 3A; 12 (15%) had 3B; 4 (5.0%) had 3C and 6 (7.5%) had 4th degree anal injuries, respectively. Forty two (52.5%) of the women had SG and 38 (47.5%) had no SG. There was no association between SG severity and OASIS (3A, 3B, 3C+4th) χ2 (6) = 8.4014; p = 0.2. As there were only 10 women with OASIS of 3C and 4, we re-analyzed the association between SG severity and OASIS severity of 3A and 3B. There was a significant association between SG severity and OASIS severity (3A, 3B) χ2 (3) = 9.306; p = 0.025. ADDITIONAL FINDINGS: women with SG were younger (mean = 26.74, SD = 3.57) than women without SG (mean = 29.29, SD = 4.40) (t(78) = 2.86, p = .005). Three symptoms had a significant reduction in the bother degree between 6 and 12 months: urinary incontinence (p = 0.017), flatus incontinence (p = 0.031) and sexuality (p = 0.016). KEY CONCLUSIONS: the innovation of this research is the association between SG severity and OASIS severity (3A, 3B), added information regarding OASIS risk factors.