Striae gravidarum

Striae gravidarum are pregnancy stretch marks, which are fine atrophic linear scars on your body that occur from tissue under your skin tearing from rapid growth or over-stretching. Striae gravidarum is the second most common skin condition after skin pigmentation during pregnancy ¹. Striae gravidarum affects between 55% ² and 90% of women ³. Striae gravidarum does not cause any significant medical problems but can be of cosmetic concern for some women. Striae gravidarum can cause emotional and psychological distress for many women ⁴.

The cause of striae gravidarum is uncertain, but it is assumed that changes in the structure of collagen, mediated by hormonal changes during pregnancy, are the causative factor. These pregnancy stretch marks normally appear during the third trimester of pregnancy and disappear several months after delivery. The most significant risk factors for striae gravidarum during pregnancy identified in this review ⁴ are younger age, maternal and family history of striae gravidarum, increased pre-pregnancy and pre-delivery weight, and increased birth weight. For prevention of striae gravidarum, creams with Centella asiatica extract such as Trofolastin cream and a daily massage seem the most supported treatment options by the literature, but further studies are necessary. This information can be helpful for future expectant mothers who would like to try preventative treatments for striae gravidarum. With regard to the treatment of striae gravidarum, skin rubbing of almond oil as well as extracts from the Centella tree have proved to be of limited therapeutic value. The current most effective therapies for striae gravidarum include tretinoin cream ≥ 0.05% and modalities such as nonablative fractional lasers. Laser treatment appears to yield on average greater mean improvement and in a much shorter time than topical treatments, but no head-to-head studies have been conducted to date. Tretinoin cream and laser treatments resulted in increased elastin content and collagen production in the treated lesions, which can partly explain the improvement observed. Many new studies that test novel laser treatments, microdermabrasion, and microneedling are underway.

Figure 1. Immature striae gravidarum (striae rubra) on the abdomen

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Figure 2. Immature striae gravidarum (striae rubra) on the thigh

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Figure 3. Mature striae gravidarum (striae alba) on the abdomen

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Striae gravidarum causes

The cause of striae gravidarum during pregnancy involves a combination of genetic factors ⁵, hormonal factors ⁶ and increased mechanic stress on connective tissue ⁷. Interestingly, skin stretch has been a controversial trigger as studies have demonstrated an inconsistent association of striae gravidarum with maternal weight gain and abdominal and hip girth stretch ⁸. With regard to hormonal factors, twice as many estrogen receptors and elevated androgen and glucocorticoid receptors have been observed in striae compared with those in healthy skin ⁹. Pregnancy’s distinct hormonal environment is thought to influence connective tissue that is susceptible to striae gravidarum when stretched. Ultimately, abnormalities in elastic fibers ¹⁰, collagen fibrils ¹¹ and other extracellular membrane components ¹² are believed to underlie the pathogenesis of striae gravidarum ¹³.

Risk factors for developing striae gravidarum during pregnancy

The most common risk factors for striae gravidarum include younger age, maternal and family history of striae gravidarum, higher pre-pregnancy and pre-delivery weight, and higher birth weight (see Table 1). Most studies showed a statistically significant association between these risk factors and striae gravidarum, although Findik et al. ¹⁴ and Chang et al. ¹⁵ did not confirm pre-pregnancy weight or maternal age as a risk factor. Most studies also demonstrated that a history of striae (stretch marks) on the breasts, hips, and thighs was associated with formation of striae gravidarum; however, a study of 299 Caucasian women showed that although striae on the breasts increased risk of striae gravidarum, striae on the thighs decreased the risk of striae gravidarum. The study by Chang et al. ¹⁵ found a higher prevalence of striae gravidarum in non-white women. With regard to socioeconomic status, multiple studies showed that unemployment, receiving state medical assistance, and lower education level were also associated with striae gravidarum. However, confounding factors should be considered. Increased alcohol intake, decreased water consumption, decreased blood vitamin C levels, and expecting a male baby were also found to be more common among those women who developed striae gravidarum in select studies ⁴. Even though it has been speculated that diabetes and increased serum glucose levels could play a part in the pathogenesis of striae gravidarum, the studies included here did not reveal an association with diabetes or glycosylated hemoglobin levels. Studies were limited by study type, size, and patient population ⁴.

Table 1. Risk factors for striae gravidarum

Investigators and Study Type	Number of Subjects and Subject profiles	Risk Factors Identified⁎	Treatments
Picard et al. 16 Cross-sectional study	800 primiparous women examined postpartum with mean age of 26.3 years	▪ Younger age ▪ Higher pre-pregnancy weight ▪ Body mass index ▪ Higher weight at delivery ▪ Higher gestational weight gain ▪ Fitzpatrick skin types 1 and 4 ▪ Absence of employment ▪ Family history of striae gravidarum	Topical treatments to reduce the occurrence of striae gravidarum were not found to be effective
Kasielska-Trojan et al. 17 Cross-sectional study	299 Caucasian women up to 6 months after delivery, without distinguishing primiparous or multiparas.	▪ Previous history of striae gravidarum ▪ Family history of striae gravidarum ▪ Higher BMI before pregnancy ▪ Lack of chronic diseases ▪ Higher birthweight ▪ Striae distensae (stretched skin) on the breasts increased risk (71.4% with striae on breasts vs. 28.6% without) ▪ Striae distensae (stretched skin) on thighs decreased risk (23% with striae vs. 77% without striae)	Progesterone treatment was not found to be related to striae gravidarum
J-Orh et al. 18 Cross-sectional study	280 Thai women who had just given birth to first child, in the immediate postpartum period.	▪ Younger age (22.8 yr vs. 26.6 yr) ▪ Higher pre-pregnancy BMI (21.2 kg/m2 vs. 19.8 kg/m2) ▪ Higher maternal BMI at pregnancy (27.3 kg/m2 vs. 25.6 kg/m2) ▪ Higher gestational age at delivery (39.1 wk vs. 38.6 wk) ▪ Higher birth weight of baby (3,078.8 g vs. 2,895.8) ▪ Alcohol drinker (91.4% vs. 8.6%) ▪ Had little water intake (7.4 glasses vs. 8.3 glasses) ▪ Family history of striae gravidarum (82.8% vs. 17.2%)	Did not assess
Osman et al. 19 Cross-sectional study	112 primiparous Lebanese women assessed during the immediate postpartum period	▪ Younger age (26.5 yr vs. 30.5) ▪ Increased weight gain during pregnancy (15.6 kg vs. 38.4 kg) ▪ Birth weight, gestational age at delivery, and family history of striae gravidarum associated with moderate-to-severe striae gravidarum	Did not assess
Atwal et al. 8 Cross-sectional study with questionnaire	309 primiparous women within 48 hours of delivery	▪ Most significant was low maternal age ▪ 20% (14 of 71) of teenagers had severe striae, not seen in ♀ over 30 yr of age. ▪ Pre-pregnancy BMI greater than 26 ▪ Maternal weight gain of more than 15 kg ▪ High neonatal birth weight	Did not assess
Chang et al. 15 Cross-sectional study with anonymous survey	161 women who had just given birth	▪ Most significant was a history of breast or thigh striae (81% who developed striae gravidarum had striae history vs. 31% without striae gravidarum who had history of striae) ▪ Having a mother with striae gravidarum ▪ Additional family history (sisters, daughters, grandmothers, aunts, cousins) of striae gravidarum ▪ Non-white ♀ had higher association with striae gravidarum (odds ratio = 4.2). ▪ Pre-pregnancy BMI not significantly different	Did not assess
Ersoy et al. 20 Prospective observational study	211 singleton primiparous pregnant women who were hospitalized for birth and who did not have systemic diseases or other risk factors, like drug use or polyhydramnios.	▪ Younger age ▪ Higher pre-conceptional BMI ▪ Family history ▪ Having a male baby ▪ Lower educational level ▪ Smoking status, skin type, water intake, and level of financial income did not significantly predict striae gravidarum	Use of preventive oil or drugs, did not affect development of striae gravidarum
Findik et al. 14 Prospective study	69 primigravidas using prophylactic iron and vitamin preparations at 36 weeks gestation or greater	▪ Family history ▪ Reduced blood vitamin C levels ▪ No significant relation with age, weight gain during pregnancy, abdominal/thigh circumference, or smoking status	Did not assess
Thomas and Liston 21 Prospective observational study	128 primigravid women who presented in labor or for induction of labor	▪ Younger age ▪ Higher pre-delivery BMI ▪ Higher baby weight	Did not assess
Davey 22 Prospective study	76 primiparous women	▪ Younger age ▪ Higher weight ▪ Higher baby weight	Striae gravidarum were less common in skin messaged with olive oil
Madlon-Kay 23 Retrospective cohort study	48 nulliparous women at 34 to 36 weeks’ estimated gestational age	▪ Younger age ▪ More likely to receive state medical assistance ▪ More likely to have hip striae ▪ Greater weight gain during pregnancy ▪ Diabetes tests and glycosylated hemoglobin levels were similar in ♀ with and without striae.	♀ who used oils or creams formed striae as frequently as those who did not

Abbreviations: ♀=women; BMI = body-mass index; mos = months; SG = striae gravidarum; yrs = years.

Striae gravidarum prevention

Preventative treatments have met with limited success. Creams that contain Centella asiatica extract, especially Trofolastin cream, are best supported by data for the prevention or reduction of the severity of striae gravidarum (see Table 2) ²⁴. Centella asiatica is a medicinal herb that is thought to increase the production of collagen and elastic fibers ²⁴. Mallol et al. ²⁵ demonstrated that Trofolastin cream with Centella asiatica extract, α-tocopherol, and collagen–elastin hydrolysates that is applied daily from gestational week 12 until delivery significantly reduced the incidence of striae gravidarum compared with placebo. Both Mallol et al. ²⁵ and García Hernández et al. ²⁴ found that creams that contained Centella asiatica significantly reduced the intensity and/or severity of striae gravidarum among women who did develop striae gravidarum. García Hernández et al. ²⁴ also demonstrated that the severity of previous striae significantly increased in the patient group treated with placebo but did not change in the patient group treated with Centella cream.

The application of almond oil, olive oil, or cocoa butter consistently failed to significantly lower the incidence of striae gravidarum compared with placebo group. Two studies did find that when olive oil or almond oil were applied with a massage daily, they were associated with a lower incidence of striae gravidarum development. However, these results may reflect the benefits of massage alone ²⁶.

Alphastria cream and verum cream, two proprietary creams that contain hyaluronic acid combined with various vitamins and fatty acids, were shown to significantly lower the incidence of striae gravidarum in two studies ²⁷. Hyaluronic acid, the active ingredient in both creams, is thought to increase resistance to mechanical forces and oppose atrophy through stimulation of fibroblast activity and collagen production ²⁸. In both studies, the creams were applied through massage during the second trimester, which poses the question of whether the creams were truly beneficial or whether the results reflected the benefits of massage alone.

Table 2. Striae gravidarum prevention

Investigators and Study Type	Number of Subjects and Subject Profiles	Preventive Methods Used	Results of Preventive Methods⁎
Mallol et al. 25 Randomized, double-blind, placebo-controlled study	80 pregnant ♀ during their first 12 weeks of a healthy pregnancy	Trofolastin cream with Centella asiatica extract, α-tocopherol and collagen–elastin hydrolysates; applied daily from 12th week of pregnancy until delivery	▪ Development of striae gravidarum: 56% in placebo group vs. 34% in treatment group ▪ Intensity of striae gravidarum was significantly lower in ♀ treated with cream vs. placebo ▪ In ♀ with history of striae during puberty, cream prevented striae gravidarum in 89% of cases, whereas all ♀ formed striae gravidarum in the placebo group
García Hernández et al. 24 Randomized, double-blind, placebo-controlled study	183 pregnant patients over age 18 at week 12 +/- 2	Cream containing hydroxyprolisilane-C, rosehip oil, Centella asiatica triterpenes and vitamin E; applied twice a day around 12 weeks of pregnancy	▪ Effective in preventing striae gravidarum only in ♀ without a history of striae (6% developed striae gravidarum on treatment vs. 35% on placebo) ▪ Severity of previous stretch marks increased in the control group during the study, but not in the treated group ▪ Among ♀ who developed new striae gravidarum, there was increased severity in control vs. treated group
Taavoni et al. 29 Randomized clinical study	70 nulliparous ♀ aged between 20-30 yrs old, in 18–20th week of gestation with BMI ranging between 18.5-25. 35 used treatment, 35 did not	Olive oil applied topically onto abdomen twice daily, without massaging, vs. no olive oil	▪ Striae gravidarum occurred at the end of the second quarter of pregnancy in 45.7% in intervention group vs. 62.9% in control group (p = 0.115) ▪ Difference NOT statistically significant
Soltanipoor et al. 30 Randomized controlled clinical study	100 nulliparous pregnant ♀; 50 used treatment, 50 did not	Olive oil applied topically onto abdomen twice daily, without massaging, vs. no olive oil	▪ Frequency of severe striae gravidarum was lower in group that used olive oil. ▪ Difference NOT statistically significant
de Buman et al 31 Randomized controlled study	90 pregnant ♀; 30 received treatment cream, 30 received vitamin cream, 30 received placebo	Alphastria cream (hyaluronic acid, allantoin, vitamin A, vitamin E and calcium pantothenate) vs. vitamin cream vs. placebo cream; messaged for a few minutes daily to the thighs, abdomen and chest, starting at the 3rd month of pregnancy and ending 3 mos after childbirth	▪ Striae gravidarum developed in 10% of alphastria treated group vs. 40% of vitamin treated group vs. 37% in placebo treated group
Wierrani et al. 27 Randomized controlled study	50 pregnant ♀; 24 received treatment, 26 did not receive any treatment	Verum cream (vitamin E, essential fatty acids, panthenol, hyaluronic acid, elastin and menthol); massaged onto the abdomen, thighs and breasts starting at the 20th week of pregnancy	▪ Striae gravidarum developed in 29% of verum treated group vs. 62% in no treatment group
Soltanipour et al. 32 Parallel randomized controlled clinical study	150 nulliparous ♀ at their second trimester of pregnancy in Iran. 50 subjects in each group	Olive oil vs. Saj® cream that contains lanolin, stearin, triethanolamine, almond oil, and bizovax glycerin amidine vs. placebo	▪ Striae gravidarum occurred in 72% of olive oil group vs. 64% in Saj® cream group vs. 60% in control group. ▪ Differences NOT statistically significant
Osman et al. 33 Randomized double-blind placebo-controlled study	175 nulliparous ♀ in Lebanon with singleton pregnancies between week 12 and 18 weeks of gestation. 91 with study treatment, 84 with placebo	Cocoa butter lotion vs. placebo lotion, daily from weeks 12-18	▪ Striae gravidarum developed in 45% of patients using cocoa butter cream vs. 48% using placebo ▪ Difference NOT statistically significant
Buchanan et al. 34 Randomized, double-blind, placebo-controlled study	300 pregnant ♀; 150 received treatment, 150 placebo	Cocoa butter lotion vs. placebo lotion, daily from 16 weeks to delivery	▪ Striae gravidarum developed in 44% of patients using cocoa butter cream vs. 55% using placebo ▪ Difference NOT statistically significant
Timur Taşhan and Kafkasli 26 Posttest-only quasi-experimental design with a control group	141 primiparous ♀ who visited the pregnancy unit in Turkey between February 1st, 2010 and April 15th, 2011. 47 subjects in oil + massage, 48 in oil – massage, 46 in control	Bitter almond oil applied with or without massage vs. control; applied every other day in weeks 19–32 of pregnancy, followed by daily until delivery	▪ Frequency of striae gravidarum: 20% among ♀ who applied oil with massage vs. 38.8% among those who applied without massage vs. 41.2% in control group
Poidevin 35 Prospective study	116 primigravidas;♀ 55 used treatment, 66 did not	Olive oil vs. no olive oil applied daily	▪ Striae gravidarum developed in 68% of olive oil group vs. 55% not using olive oil. ▪ Difference NOT statistically significant
Davey 22 Prospective study	76 primiparous ♀; 35 used treatment, 41 did not	Olive oil massaged into abdomen daily vs. no olive oil	▪ The prophylactic use of olive oil to massage the abdomen was associated with a lower incidence of striae gravidarum

Abbreviations: ♀=women; BMI = body-mass index; mos = months; SG = striae gravidarum; yrs = years.

Striae gravidarum signs and symptoms

Striae gravidarum first present as flat, pink-to-red bands (striae rubra or immature striae) that become raised, longer, wider, and violet-red (Figures 1 and 2). Over a period of months to years, the stretch marks fade and become hypopigmented (striae alba or mature striae), appearing parallel to skin tension lines as scar-like, wrinkled, white, and atrophic marks (Figure 3) ³⁶. Striae gravidarum can cause itching, burning, and discomfort and typically present on the breasts, abdomen, hips, and thighs. Up to 90% of striae gravidarum appear in a woman who is pregnant for the first time (primigravida) ¹⁵. Onset has typically been reported in the late second and early third trimester; however, one study has demonstrated that 43% of women develop striae gravidarum prior to 24 weeks of gestation ¹⁵.

Striae gravidarum treatment

Striae gravidarum treatment should be instituted during the early stages of striae gravidarum rather than when striae have matured and permanent changes have occurred ⁴. Many homeopathic and alternative therapies, including fruit and vegetable oils that hydrate the skin, are employed but limited by insufficient evidence.

Table 3. Striae gravidarum treatment options

Investigators and Study Type	Number of Subjects and Subject Profiles	Type of Striae	Treatment	Efficacy⁎	Adverse Effects
Malekzad et al. 37 Prospective pilot study	10 ♀ aged 26-50, Fitzpatrick skin types 3 to 5	Striae alba	1540-nm non-ablative fractional laser	▪ Clinical improvement in striae ranging from 1-24% ▪ Improvement between the 4-week treatment and the 16-week treatment was identified ▪ 3 mos after final treatment, patients had observable improvement in the striae, compared with baseline	Mild post-inflammatory hyperpigmentation in one patient after 8-week treatment and mild acne in another patient after 4 weeks of treatment
Rangel et al. 38 Open-label, multicenter, prospective study	26 ♀ with abdominal pregnancy-related striae	Not reported	0.1% tretinoin cream daily for 3 mos applied to SG	▪ At treatment conclusion, global improvement was achieved from baseline in all stretch marks ▪ Pre-selected target lesion decreased in length by 20% and width by 23%	Erythema and scaling were the most common adverse events
Pribanich et al. 39 Double-blind placebo controlled study	11 non-pregnant ♀ who had SG, 6 received treatment and 5 placebo	Not reported	0.025% tretinoin cream applied daily for 7 mos	▪ No statistically significant difference in treated group compared to control group	Did not assess
Kang et al. 40 Double-blind, randomized, vehicle-controlled study	22 healthy white ♀ with erythematous stretch marks, 10 received treatment and 12 vehicle	Striae rubra	0.1% tretinoin (n = 10) or vehicle (n = 12) daily for 6 mos to the affected areas	▪ At 2 mos, tretinoin patients had significant improvements in severity scores of SG vs. vehicle patients ▪ At 6 mos, 80% of tretinoin patients had improvement vs. 8% of vehicle patients ▪ Targeted stretch marks treated with tretinoin had decrease in mean length and width of 14% and 8%, respectively, vs. an increase of 10% and 24%, respectively, in vehicle patients	Erythema and scaling, with itching and burning
Ash et al. 41 Randomized controlled study	10 American nonpregnant ♀ of varying skin types, age 23 to 49 yr. Striae age ranged from 8 mos to 31 yr and all were white striae. All patients had abdominal striae, 50% also had striae on thighs	Striae alba	20% glycolic acid + 0.05% tretinoin vs. 20% glycolic acid + 10% ascorbic acid, applied daily to abdomen or thighs for 12 weeks (each regimen was applied to half the treatment area)	▪ At treatment conclusion, 47% improvement with 0.05% tretinoin vs. 43% improvement with ascorbic acid ▪ Results not statistically significant from each other, but significant for both compared to pretreatment ▪ 0.05% tretinoin increased elastin content at sites vs. untreated striae by 22% in the papillary and reticular dermis combined ▪ 10% L-ascorbic acid failed to improve elastin content in either the papillary or reticular dermis ▪ Both regimens increased epidermal thickness and decreased papillary dermal thickness	70% of patients experienced mild irritation at treatment initiation on both treatment sites. A single patient developed a mild irritant dermatitis

Abbreviations: ♀=women; BMI = body-mass index; mos = months; SG = striae gravidarum; yrs = years.

Topical medications

Tretinoin cream and a combination of 20% glycolic acid + 10% ascorbic acid were shown to improve striae gravidarum in clinical studies (see Table 3 above). Use of tretinoin 0.05% and 0.1% creams on a daily basis for 3 to 7 months consistently resulted in overall global improvement of striae gravidarum up to 47% ⁴¹ and decreased in mean length and width up to 20% and 23% respectively ³⁸, of lesions. A study by Pribanich et al. ³⁹ showed that the minimum effective concentration of tretinoin cream is 0.05%. Twenty percent glycolic acid combined with either 10% ascorbic acid or 0.05% tretinoin improved the appearance of striae gravidarum although there was no statistically significant difference between the two combinations ⁴¹. Tretinoin increased elastin content in the papillary and reticular dermis of the lesions but ascorbic acid and untreated areas did not show such improvement. Both treatments increased epidermal thickness and decreased papillary dermal thickness in striae gravidarum lesions.

Laser treatments

A 1540-nm non-ablative fractional laser demonstrated a statistically-significant clinical improvement in striae gravidarum that ranged from 1 to 24% and an observable difference at 3 months post-treatment³⁷. For nongestational striae distensae (stretched skin), both fractional and non-fractional lasers have been employed with varying efficacies.

Among fractional lasers, both non-ablative Erbium (Er):Glass and ablative carbon dioxide (CO2) lasers have been studied. An average of 50 to 75% improvement in lesions after 2 to 6 nonablative Er:Glass treatments has been reported ⁴². Histologic studies showed an increase in elastic fibers and collagen production. This laser was generally safe and treatments were well-tolerated by patients. In a study by Lee et al. (2010), ablative CO2 lasers were demonstrated to have improvements of 50 to 75%, especially in striae alba. However, other studies have shown inconsistent results ⁴³. CO2 lasers are more painful and may have longer recovery times than non-ablative lasers.

Among non-fractional lasers, excimer, pulsed dye, neodymium-doped yttrium aluminum garnet (Nd:YAG), copper bromide, and diode have been studied in the treatment of patients with nongestational striae distensae (stretched skin). The excimer 308-nm laser is used to treat mature striae alba by producing repigmentation and has achieved up to 75% increase in pigmentation; however, results are generally temporary and pigmentation of the normal surrounding skin is an unfavorable consequence ⁴⁴. Pulsed dye laser results in textural improvements but has shown a limited benefit to treat striae alba ⁴⁵. It may be beneficial in striae rubra by reducing erythema ⁴⁶. Nd:YAG laser, also a vascular laser, demonstrated excellent improvement of up to 70% or more, even though it is specifically for immature striae rubra ⁴⁷. Thirteen of 15 women experienced a complete resolution or modest improvement of striae for up to 2 years in a small study that used copper bromide laser ⁴⁸. The diode laser was used to treat striae distensae (stretched skin) in dark-skinned individuals but this laser was ineffective and 64% of patients developed undesirable hyperpigmentation ⁴⁹.

Light treatments

Light therapy modalities such as intense pulsed light (IPL), ultraviolet (UV) light, and infrared light have been employed for the treatment of nongestational striae distensae (stretched skin). Intense pulsed light (IPL) seems to result in at least moderate improvement of striae ⁵⁰, but persistent erythema and post-inflammatory hyperpigmentation may complicate this treatment. UV light, especially a combination of UV-B and UV-A, has been shown to consistently repigment striae alba. However, the results are not permanent and maintenance treatment is required ⁵¹. Infrared light at 800 to 1800 nm can result in 25 to 50% improvement in striae alba after only four treatment sessions ⁵². Long-term studies with larger sample sizes are needed to confirm these results.

Other treatments

Bipolar radiofrequency demonstrated clinical and histologic improvements in striae distensae (stretched skin) ⁵³, while tripolar third generation radiofrequency (Tripollar) resulted in 25 to 75% improvement at 1 week post-final treatment ⁵⁴. Modalities such as microdermabrasion and microneedling have been found to be effective to improve nongestational striae in multiple studies. Microdermabrasion has been especially effective for striae rubra ⁵⁵. Microdermabrasion involves the blowing and subsequent vacuuming of abrasive substances to a treated area. Another study found that although microdermabrasion with sonophoresis improved striae, needling therapy yielded an even greater, statistically-significant improvement in striae compared with microdermabrasion ⁵⁶. Needling therapy causes controlled skin injury with the goal of producing new collagen and elastin in the papillary dermis.

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