What are the most effective treatments for a patient presenting with striae (stretch marks) on the skin?

Treatment of Striae Distensae (Stretch Marks)

For patients presenting with striae distensae, the most effective treatment is combination therapy using platelet-rich plasma (PRP) with fractional CO2 laser, which demonstrates superior clinical outcomes, patient satisfaction, and histopathological improvement compared to other modalities. 1

Primary Recommendation: Combination PRP with CO2 Laser

The 2025 guidelines from Periodontology 2000 provide the strongest evidence for treating stretch marks with combination approaches rather than monotherapy. 1

Key findings supporting this recommendation:

• PRP combined with fractional CO2 laser showed significantly better results than PRP with pulsed dye laser (PDL), with higher patient satisfaction and fewer side effects 1
• Histopathological analysis demonstrated improvement in epidermal thickness, normalized orientation of dermal collagen fibers, and increased rete ridge formation with PRP-CO2 laser combinations 1
• Combined fractional CO2 laser with intradermal PRP achieved 60.33% excellent improvement rates compared to CO2 laser alone, with more significant dermal deposition of collagen and elastic fibers 1

Alternative Combination Therapies (When CO2 Laser Unavailable)

If fractional CO2 laser is not accessible, other evidence-based combination approaches include:

PRP with Microneedling

• Demonstrated statistically significant improvement over microneedling alone for stretch mark appearance 1
• Treatment with combined microneedling and PRP showed significantly higher collagen and elastin fiber deposition compared to microneedling only 1
• Typically administered as three sessions at 1-month intervals 1

PRP with Intradermal Radiofrequency

• 63.2% of patients reported being "satisfied" or "very satisfied" with overall improvement 1
• Clinical results showed 5.3% excellent improvement, 36.8% marked improvement, 31.6% moderate improvement 1
• Increased collagen density subepidermally on histology 1
• Protocol: three sessions at 6-week intervals 1

PRP with Microdermabrasion

• Combination therapy produces better results in shorter duration than either treatment alone 1
• PRP alone is more effective than microdermabrasion alone, but combination yields optimal rapid efficacy 1

Critical Timing Consideration

Early treatment initiation is essential for optimal outcomes. 1 The guidelines explicitly state that "the earlier treatment is initiated, the better the outcome," emphasizing the importance of treating striae rubrae (red/early stretch marks) rather than waiting until they become striae albae (white/mature stretch marks). 1

Topical Therapies: Limited Evidence

While topical agents are commonly used, the evidence supporting their efficacy is weak:

• Tretinoin 0.1% combined with 20% glycolic acid showed some improvement in striae alba with increased elastin content and epidermal thickness, but effects are modest 2
• Cocoa butter and olive oil demonstrated no effect in preventing or treating stretch marks 3
• Trofolastin and Alphastria creams showed level-2 evidence for prophylactic use only, not therapeutic treatment 3
• Overall, topical therapeutic agents appear to lack efficacy in both prevention and treatment of established striae 4, 3

Important Clinical Caveats

Avoid common pitfalls:

• Do not rely on monotherapy approaches—combination treatments consistently outperform single modalities 1
• Do not delay treatment waiting for spontaneous improvement—early intervention is critical 1
• Do not use topicals as primary therapy for established stretch marks—they lack sufficient evidence for therapeutic (vs. prophylactic) use 4, 3

Patient counseling should include:

• Avoidance of further triggers such as excessive weight gain or loss, and chronic corticosteroid use 1
• Realistic expectations—while combination therapies show "quite nice clinical outcomes and patient satisfaction," complete resolution is uncommon 1
• Treatment variability—there is "much more variability in this space" compared to other dermatologic conditions 1

Evidence Quality Assessment

The 2025 Periodontology 2000 guidelines acknowledge that "clinical trials on APCs and their effect on striae distensae are scarce and their level of evidence mostly poor," and "there is no use of a standardized assessment scale for the subjective evaluation of SD." 1 Despite these limitations, the consistent findings across six studies showing superiority of combination approaches over monotherapy provides the best available evidence for clinical decision-making. 1

The treatment algorithm should prioritize:

1. First-line: PRP + fractional CO2 laser (3 sessions, 6-week intervals)
2. Second-line: PRP + microneedling or PRP + intradermal RF (3 sessions, 4-6 week intervals)
3. Adjunctive only: Topical tretinoin + glycolic acid for mild cases or patient preference