Stretch mark treatement
There is no gold standard therapy for the treatment of stretch marks. Most medical professionals will recommend treatment while stretch marks are in their most active stage – striae rubrae (i.e. when they are still newly formed and purple/red in colour). Once mature (i.e. one they have faded and taken on a white or silvery appearance), stretch marks are more difficult to eradicate.
There are plenty products on the market, all promising the ability to reduce / eradicate the appearance of or even prevent stretch marks (especially during pregnancy), but very few have been formally trialled in high-quality clinical studies. Those which have, have not all shown the most promising or reliable of results. Findings are variable with minimal improvements achieved, if any at all.
The availability of so many commercial products has prompted many studies assessing ingredients used which claim to be 'the best' in ridding the body of stretch marks. Researchers have looked at various angles in order to find the most effective products or procedural treatment measures that are also safe to use. Some of these angles have assessed the potential of existing therapies aimed at treating other skin-related conditions (like acne and scarring due to various causes), and whether off-label use can have any significant influence on attaining the desired effect when it comes to reducing or eliminating the appearance of stretch marks.
Topical and deep-stimulating procedural therapies are currently the most commonly used means for treating stretch marks with some degree of effectiveness.
The main goals of treatment are aimed at improving the appearance of stretch marks and returning the skin as closely as possible to its former quality. Thus, it has been determined that treatment therapies must address the following in order to be most effective:
- Reduce inflammation (discolouration and oedema / swelling)
- Increase collagen production
- Stimulate fibroblastic activity, elasticity and blood perfusion (oxygenated blood that is sufficiently delivered to tissues of the body)
- Improve hydration of the skin
- Successfully administer anti-inflammatory properties
- Improve cell proliferation (a healthy balance between cell production and division, as well as cell loss / skin cell shedding)
To date, none of the available therapies have been scientifically able to completely eradicate stretch marks – whether in their early or late stages of development. With that in mind, let’s look at what’s been clinically researched, and which treatments have thus far shown the most reliable results…
At-home stretch mark treatment
Many products and natural ingredients have been associated with getting rid of stretch marks. But which ones are worth a try? And just how many actually do carry some scientific weight in terms of effectively treating, or even preventing stretch marks?
1. Natural anti-inflammatory / skin healing agents
Indicated as an important factor for improving skin quality associated with treating stretch marks (and especially early stage formations), the following anti-inflammatory / skin healing agents are commonly used in stretch mark treatment products:
- Coconut oil: Virgin coconut oil and cultured coconut extract (i.e. virgin coconut oil which undergoes a bacterial fermentation process) have been highlighted as potential anti-inflammatory agents which may be helpful in the home treatment of stretch marks. Their high polyphenol content and fatty acid components have had some success in showing the oil to be an effective anti-inflammatory and potentially collagen boosting product. (4)
- Almond oil: This natural substance has long been used to help soothe and rejuvenate skin affected by dehydration (and is often used in products promoting the improvement of skin tone and complexion) and skin conditions like psoriasis and eczema. It has even been looked at for the treatment of post-operative hypertrophic scarring (deposits of excess collagen resulting in a raised scar on the skin). (5) Almond oil is thus a natural ingredient that is regarded as having a reparative effect, also helping to soothe skin irritation. Its high concentration of vitamin E is also thought to be helpful in the prevention of stretch marks.
- Vitamin C: Known to be a potent anti-oxidant, vitamin C has widely been used in dermatology for some time, treating conditions like hyperpigmentation (an overproduction of melanin causing darkened skin patches) by acting as a depigmentation agent. It can protect the skin from oxidative stress and also helps to neutralise free radicals. Vitamin C is an important factor in the biosynthesis of collagen, stimulating and stabilising collagen molecules. Vitamin C is thus able to help improve collagen production in skin of any age. It is is also regarded as an effective ingredient in topical treatments thanks to its anti-inflammatory properties. It serves as an inhibitor of NF-kB (nuclear factor kappa-light-chain-enhancer of activated B cells), which is involved in the activation processes of inflammatory cytokines (secreted by cells of the immune system with an inflammatory effect on other surrounding cells). (6) For this reason, it is a common ingredient used in the treatment of acne vulgaris and rosacea, with wound healing benefits.
- Aloe Vera: This natural extract is used in a wide range of products promoting wound healing. It is also a popular natural treatment remedy that has been used by Egyptian, Greek, African and Spanish communities for centuries. The polysaccharide content (polymeric carbohydrate molecules) in aloe Vera helps to stimulate healing and skin growth. The water-soluble polysaccharide, glucomannan helps to improve the secretion and production of collagen in the skin. By improving the structure of collagen, these compounds actively accelerate wound healing. (7) Aloe Vera is also enriched with both vitamin C and E compounds for added healing and anti-inflammatory effects.
Natural ingredients have been used throughout history and are commonly incorporated in many modern cosmeceutical products with the overall aim of improving skin quality. Research findings have shown that there is some degree of benefit to be gained by using natural products. Many natural ingredients have multiple, proven health benefits, and thus the use of any of these substances is not likely to cause any further harm to the skin.
While these naturally based substances have a relatively good safety profile, enough scientific evidence in the way of directly and effectively ridding the body of stretch marks specifically has not been conclusively established.
If any of these substances are used, a doctor (dermatologist) may recommend their use over an extended period of time (with the applications being massaged into the affected skin areas daily for at least several months). Since there is no gold standard treatment for stretch marks, there is no quick fix therapy either. As such, consistent use of specific products containing ingredients / agents indicated for skin improvement (whether natural or not) may become a regular expense for the consumer.
2. Stretch mark creams, lotions and potions – Which ones actually work?
Topical treatment of stretch marks is the most commonly used management measure for stretch marks, these applications contain an assortment of ingredients indicated for striae improvement. A limited number of these products have been clinically studied with the majority of findings being predominantly viewed as low quality (i.e. level 1 / 2 evidence) due to the small scale of assessment conducted. Findings of higher quality are normally attributed to studies that are well-designed and well-conducted, producing clear and well-defined evidence. Many studies are thought to have been conducted in a way that shows bias or have not produced well-defined results at all.
To date, the majority of studies with available information are lacking in reliable data and have not proven anything specific in the way of valid treatment when it comes to ridding the skin of striae. Many studies have also not indicated at what stage use of a particular product is most effective either.
Most topical treatments are aimed at improving the texture of the skin affected by striae and pigmentation, while resulting in very few, if any, side-effects. All products aimed at having this effect must promote collagen production and fibroblast activity, improve elasticity, cell proliferation and blood perfusion, as well as offer anti-inflammatory properties and enhanced skin hydration – all factors that stand to improve the overall quality of skin. So, what have studies been able to determine?
The most effectively studied topical product: Topical retinoids
The use of topical retinoids (chemical compounds which regulate epithelial cell growth) has been shown to be most effective for the treatment of striae rubrae. One of the most effective agents is a retinoid known as tretinoin (retinoic acid). This compound has been assessed for its therapeutic effect in several case studies (clinical trials) that have produced higher-quality evidence levels.
Findings showed greater efficacy when implementing treatment during the striae rubrae stage of stretch mark development, with limited improvement capabilities in more mature stretch marks.
This compound administered at a dose of 0.1% on a daily basis for at least 6 months has shown a marked reduction in both the length (up to 14%) and width (up to 8%) of early stage stretch marks. Within 2 months of use, improvements are already noticeable. (8) Lower concentration doses trialled did not appear to prove as effective, even if used for longer periods of time.
Some skin irritation (inflammation) was experienced during trials and thus can be expected in some patients using creams with a 0.1% concentration dose of tretinoin. Inflammatory reactions (resulting in redness of the skin known as erythema) or scaling that develops can be effectively managed with emollient creams (moisturising creams manufactured to restore hydration to the skin, making it softer and more pliable) at concentrations of at least 0.05%. These creams will also be helpful in alleviating any post-inflammatory hyperpigmentation that may occur along with the inflammatory side-effects which are more common in lighter complexion skin types ranging from fair / white to olive brown).
Currently topical retinoids are used ‘off-label’ (i.e. used for skin conditions other than the one for which they were originally approved) for the treatment of stretch marks. Topical retinoids used for effective management of early stage striae are adapalene (primarily used in the management of mild / moderate acne) and tazarotene (primarily used to treat acne, psoriasis and sun damaged skin), both of which are available through prescription.
Topical products available over-the-counter
Commercially sold products have undergone some research analysis so as to assess their efficacy in relation to the promise they make to the consumer. Many studies have been small randomised control studies which serve as an evaluation to determine any potential bias when testing a new treatment measure. These products may address some of the aspects relating to the main treatment goals in the management of stretch marks.
Assessments of some products (and their active ingredients) indicated for stretch mark management include those which may…
1. Help to stimulate collagen production and thereby skin elasticity:
- StriVectin skin repair cream (used for stretch marks, ageing skin and wrinkles)
- Cussons® Mum and Me Bump Stretch Marks Cream (containing lupin seed extract / hydrolysed lupin - indicated for collagen stimulation)
- Liforma® Stretch Mark Day Gel and Night Cream (contains centella asiatica – a perennial plant native to the wetlands of Asia, often used as a medicinal herb)
- Trofolastin (marketed as an anti-stretch / stretch mark prevention cream containing centella asiatica, collagen-elastin hydrolysates and tocopherol, which are organic compounds with vitamin E activity)
- Clarins® Stretch Marks Cream (contains centella asiatica extracts, crowberry extracts – a fruit with potent antioxidant properties, olive, palm and coconut oils, and siegesbeckia / St. Paul’s wort – often used in traditional medicine for skin-related conditions)
- Bio‐Oil® (indicated for use in the management of scars, evening of skin tone and stretch marks)
- Kelo‐Cote® silicone gel (indicated for improving the appearance of atrophic scars as a result of acne or chickenpox and stretch marks) and Kelo‐Stretch™ (containing titrated extracts of centella asiatica, sweet almond oil and shea butter indicated to help reduce the width of stretch marks when used twice daily)
- Apothederm™ Stretch Marks Cream (indicated to help reduce the appearance of early and late stage stretch marks with active ingredients – shea butter, cocoa butter, meadowfoam seed oil and olive oil)
- Skinception™ Intensive Stretch Marks Therapy Cream – Registril (Phaseolus lunatus extract / proteins of a lima bean, rutin – a citrus flavonoid, and 2 matrikines – developed replicas of the natural skin variation - extracellular matrix-derived peptides), Darutoside (contains siegesbeckia orientalis and centella asiatica), and Pro‐Sveltyl (indicated as a strong anti-cellulite agent)
- Alphastria (indicated for the prevention of stretch marks, containing hyaluronic acid)
2. Help to improve cell proliferation
- Thalgo®Stretch Marks Cream (containing marine elastin, marine collagen, centella asiatica extract, wheat germ and tamanu oils)
- Liforma® Stretch Marks Cream (contains panthenol / vitamin B5 which is indicated for improved cell production)
3. Help improve signs of inflammation
- SilDerm™ Stretch Mark Repair Cream (contains registril and darutoside)
- Liforma®Stretch Marks Cream (this product also contains vitamin E and chamomile which are indicated as anti-inflammatory ingredients)
4. Helps to restore hydration to the skin
- Palmers® Cocoa Butter cream (contains cocoa butter, elastin, collagen and vitamin E – indicated as a preventative treatment cream – a popular choice among pregnant women)
Not all of these products have been extensively studied and few have shown any significant impact when it comes to the prevention or effective management of stretch marks – any change in appearance achieved may be minimal, often working best with massage techniques (which are often recommended for managing the appearance of scars).
Some of the studied products have not specified details regarding the stage of development (rubrae or albae) at which use can be most effective. Thus, not all products available may show the same results for the different stages of stretch marks. This means that the improvements achieved as a result of their use will also vary amongst consumers. Several product studies are noted as being conducted as single-blinded studies which could therefore have produced a positive bias result.
Some product manufacturers have also only made certain result findings available for public viewing but have not allowed access to the full published research conclusions. Other products which are indicated for use in stretch mark treatment but have not made their research findings available include TriLASTIN‐SR® and RegimA® Scar Repair and Anti‐Stretch Complex.
Results from many comparative studies are also viewed as subjective and thus do not show direct efficacy when it comes to stretch marks specifically.
While some of the active ingredients are not entirely harmful to the skin, lotions, creams and serums, may only be addressing some of the primary goals of treatment. Results which can be achieved may be varied and minimal, but many of these products do contain active ingredients with some beneficial effect to the skin.
Topical therapies for the prevention of stretch marks during pregnancy
Stretch marks experienced during pregnancy are a fairly common physiological change impacting the connective tissues, mostly affecting a woman’s abdominal, breast and thigh areas – where stretching of the skin mostly occurs due to weight gain and as a result of a growing foetus. In terms of risk factors, every woman of any ethnicity can develop stretch marks and may experience them during her first pregnancy, and / or subsequent gestation periods.
Stretch marks which develop vary in severity and / or quantity and are associated with hormonal influences, as well as the physical stretching of skin. Striae are at their most unsightly during pregnancy but begin to fade, reaching a more mature stage within 6 months following the birth of a baby, becoming pale with a wrinkled texture. (9)
For many women, stretch marks are a ‘side-effect’ of pregnancy, if you will, and a cosmetic concern. There are thus topical products available that primarily address management in a prophylactic capacity (i.e. as a preventative measure). Since stretch marks are difficult to eradicate, prevention is a more desirable approach than cure. But can stretch marks really be prevented with the use of topical creams and lotions during pregnancy?
The short answer is no, no entirely. To date there has been no high-quality research findings that can conclusively make this promise. As with research for stretch marks in general, studies conducted with striae gravidarum as the primary focus have been equally limited, showing only minimal effect. In addition, it is recommended that large trials may be required to truly show any benefit which can be achieved through the use of the available products, as well as if product application (i.e. massage) has any treatment value.
Since the most effectively studied topical product, tretinoin, is not indicated as safe to use during pregnancy (with use thereof potentially increasing the risk of birth defects) or while breastfeeding, many women opt for over-the-counter commercial products with active ingredients like plant and vitamin extracts, often suspended in an oil base. Popular cosmetic products used by women during pregnancy thus include Bio Oil, and those containing cocoa butter, coconut oil and almond oil as ingredients.
With such a high percentage of pregnant women developing stretch marks, it is a good idea to request the advice of a maternity care provider during pregnancy if one is particularly concerned about the risk thereof. Those in-the-know with up-to-date information, like medical professionals, can offer the best advice when it comes to such dramatic connective tissue changes and how to best care for the skin overall. No maternity care provider can promise the prevention of striae formation during pregnancy, but many can recommend safe and reasonably effective products that may be helpful preventative measures.
A woman can also opt to wait until after her baby is born to try topical retinoids or laser therapy to treat any stretch marks that have developed, helping to reduce their appearance. Further larger, trials down the line may help to resolve current uncertainties surrounding stretch mark treatment and pinpoint the best products to use for preventative means, as well as in treatment management for more mature stretch mark formations post birth.
The most effective (deep-stimulating) procedural therapies for stretch marks
Laser treatment, like topical tretinoin is better studied with reasonably higher success rates in managing the appearance of stretch marks. Laser treatment is preferable during the earlier stages of stretch mark development and is available as an alternative to topical retinoids.
Like topical tretinoin, treatment is not a one-time-fix method – laser treatment requires multiple applications over several months and can result in some skin irritation. Laser treatment is also unpredictable – considerable improvement has been accomplished in some individuals, but not in others. Like the formation of striae themselves, treatment effectiveness varies from person to person.
If a person is opting to try such treatment measures, a comprehensive discussion with a dermatologist or cosmetic surgeon is recommended. Through this discussion, a patient can be made aware of all possible outcomes or side-effects, particularly if they have skin types known to be more prone to dyspigmentation. Fairer skin phototypes are most at risk of this – these individuals will be advised to take strict sun-protective measures following all treatments.
1. Pulsed dye lasers
Mild to moderate improvements in the appearance of stretch marks can be achieved with flash lamp pulsed dye lasers. This type of laser technology is aimed at lightening the effects of abnormal blood vessels in the skin (i.e. reducing erythema) by targeting haemoglobin (the red protein responsible for transporting oxygen in the bloodstream and also giving blood its red colour). Thus, treatments (offered as a series over a specific period of time – usually every 4 to 6 weeks) are ideally most effective during rubrae stages of stretch mark formation.
Some success in improving the overall appearance of stretch marks can be achieved during the more mature stages in some individuals too. Pulsed dye lasers at low energy densities can also help to improve the overall texture of the skin as well as stimulate collagen and elastin production.
During this procedure, an intense burst of light is delivered in short, repeated pulses to selective areas of skin affected by stretch marks. The body’s blood vessels and melanin pigmented areas of the epidermis absorb the light with each pulse delivery which is adjustable according to wavelength, duration and energy settings. A patient is likely to feel a slight sting on the surface of the skin as light is delivered. A cooling mist may be used to alleviate this sensation and bring about better levels of comfort during treatment. The cooling mist can also help to minimise inflammatory reactions.
To improve safety, both the patient and medical professional operating the laser will wear protective eyewear during a treatment session.
Spotty discolouration and /or bruising are adverse reactions which may occur with this type of laser therapy, usually as a result of blood vessel (vascular) inflammation. Other potential side-effects include post-inflammatory hyperpigmentation or blistering. Scarring of the skin is rare, but also possible in some patients.
A dermatologist or cosmetic surgeon will exercise caution when treating stretch marks in patients with fair complexions due to the risk of dyspigmentation. Extreme caution will also be exercised for darker skinned patients with prominent markings as they may be more susceptible to epidermal injury.
2. Fractional lasers
Stretch mark treatment with fractional lasers is available in two variations – ablative and non-ablative fractional lasers, both of which are commonly used for skin resurfacing and the stimulation of collagen production.
Laser treatments are intended to cause ‘injury’ to the skin layers in order to stimulate a healing process. Laser beams, divided into thousands of tiny columns (microtherma treatment zones / MTZs) are delivered to the skin. These MTZs expel epidermal cells and penetrate collagen in the dermis layer, stimulating production. Healthy tissues are unaffected by the laser columns and remain intact.
Ablative lasers work primarily with the skin cells of the surface of the skin (epidermis). Non-ablative lasers primarily target the mid-layers of the skin.
Ablative lasers are typically used to restructure or resurface skin that is affected by scarring, pigmentation abnormalities or lesions. As such, the effect can be ‘invasive’ (‘destroying’ skin tissues), leading to swelling and redness, among other adverse effects like skin peeling which can last for a few weeks.
Non-ablative lasers are a less invasive variation and heat up skin tissues to stimulate collagen production without resulting in any tissue destruction. These lasers remove fractionated (small) areas of the mid layers of skin, using a microsurgery technique known as photothermolysis. Multiple treatments increase collagen production and thereby improve the texture and tone of the skin. Milder swelling and redness is to be expected from treatments with little to no downtime required.
For both forms of fractional laser therapy, a topical anaesthesia / gliding gel (to serve as a contact lubricant) is used, as well as a cooling mist to provide comfort for the patient.
A medical professional will take into consideration the depth and age of stretch marks before deciding which form of fractional laser may have the most desired effect. Skin complexion is also something a medical professional will take into careful consideration. Darker skin tones may be at higher risk of irreversible pigmentation alterations or permanent scarring. Low density settings on the laser may be preferable to reduce such risks.
Fewer treatments (1 to 3 treatments every 4 to 6 months) are required for ablative lasers due to their invasive nature and higher risk for adverse reactions. Thus, a non-ablative approach may be favoured by medical professionals and can involve between 3 and 6 treatments administered once a month.
With multiple treatments, fractional lasers have shown some success in improving skin texture and hypopigmentation (dyspigmentation) associated with striae albae in just a few months. Mild improvements have been achieved with both ablative and non-ablative fractional laser treatments on patients with either acute or mature stage stretch marks. Some medical professionals may recommend dual treatment approaches with a non-ablative fractional laser and a pulsed dye laser for more mature stretch marks.
3. Other treatments for stretch marks
Various procedural therapies primarily used for other skin problems have also been tried on stretch marks. Any studies done have been small and uncontrolled with mildly effective (and variable) results. A medical professional can discuss the below options with a patient once stretch marks have been thoroughly assessed to determine if any may produce the desired results. A patient should ask about all of associated risks or complications before deciding to try any of the below.
- Superficial dermabrasion: A mechanical resurfacing of the skin, this procedure removes a portion of the epidermal layer affected by stretch marks, using an abrasive tool. Studies conducted have shown some mild improvement in reducing the appearance of acute stretch marks (striae rudrae). This procedure can be as effective as using topical tretinoin for several months. (10). Superficial dermabrasion has a low risk of side-effects, but scaling, redness and itching can occur temporarily.
- Phototherapy / light therapy: A non-invasive procedure, light energy can be used to help regenerate the skin cells affected by stretch marks. Improvements in hypopigmentation have been seen with more mature stretch marks using ultraviolet B (UVB) range excimer lasers. An alternative is narrowband UVB/UVA1 phototherapy. Maintenance treatments may be required as the beneficial laser effects have been known to lessen over a period of time. Skin texture may not show signs of improvement using light therapy. Side-effects can include some skin redness, burning sensations or hyperpigmentation of the skin alongside that which is affected by stretch marks.
- Chemical peels: Superficial chemical peels can help to stimulate collagen production through inducing minor ‘injury’ to the affected skin. Glycolic acid chemical peels may help to improve the appearance of both acute and mature stage stretch marks with a slight indent in the skin. Skin redness, scaling and hyperpigmentation are some of the more common side-effects associated with the procedure. A medical professional will exercise caution on fairer skin types so as to reduce the risk of post-inflammatory pigmentation changes.
- Intense pulsed light (IPL therapy): A potential alternative to pulsed dye laser therapy, IPL therapy is often used in the treatment of acne and other vascular lesions, pigmented lesions and unwanted hair. Colour changes, texture and width may be improved with IPL therapy, especially in more early stage stretch marks. IPL therapy has also been seen to stimulate collagen production in the skin, but not as much as with pulse dye laser therapy. Side-effects are minimal but can include skin redness, blistering, dyspigmentation and more rarely, scarring.
- Radiofrequency devices: A dermal re-modelling procedure, these devices use radio frequency energy to heat the surface of the skin, helping to tighten it (stimulating collagen production) and in so doing, provide moderate improvement to stretch mark formations. Radiofrequency devices can be used in combination with pulsed dye laser treatment without inducing injury (ablation) to the epidermis.
- Infrared lasers: Moderate collagen stimulation may be achievable for early stage stretch marks using a neodymium-doped yttrium aluminium garnet (laser). Mild swelling and skin redness are typical side-effects of treatment.
Procedural treatment measures, at best, can help to improve the colour and texture of the skin affected by stretch marks, stimulate collagen production in the dermal layer, as well as the synthesis of elastin. Total removal of stretch marks should not be expected with any of the treatments currently available. While the aforementioned have all seen some improvement, none have shown 100% eradication of stretch marks, even during acute / early stages.
The earlier treatment measures are applied to stretch marks, however, the better. Striae rubrae have shown better response and improvements to both topical and procedural treatment measures than striae albae.
For the time being, larger population clinical trials looking at both individual and combination therapies could determine higher-quality outcomes for better, more reliable and long-term stretch mark treatment.
Can stretch marks be prevented?
In much the same way as treatment options for existing stretch mark formations are lacking in high-quality clinical evidence, so too are those indicated for preventive use.
Trying to prevent stretch marks in pregnancy is common and topical interventions are widely used. Randomised studies have not shown direct conclusive preventative results, especially for women during pregnancy or adolescents.
When it comes to other risk profile groups, weight management can go a long way in avoiding rapid growth-related stretching of the skin. A nutrient-rich diet laden with vitamins can help to maintain healthy skin and boost collagen synthesis from the inside. Zinc is another nutrient that has a role in alleviating inflammation and stimulating wound healing in the body.
There is thus, no ideal way to prevent or treat stretch marks with any certainty. Should they develop, and a person become distressed by their appearance, it is best to seek a medical opinion regarding the current best means of managing them.
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6. US National Library of Medicine National Institutes of Health. April - June 2013. Vitamin C in dermatology: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3673383/ [Accessed 26.02.2018]
7. US National Library of Medicine National Institutes of Health. 19 May 2015. The Review on Properties of Aloe Vera in Healing of Cutaneous Wounds: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4452276/ [Accessed 26.02.2018]
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9. US National Library of Medicine National Institutes of Health. September 2016. The use of anti stretch marks’ products by women in pregnancy: a descriptive, cross-sectional survey: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5031338/ [Accessed 26.02.2018]
10. Journal of the American Academy of Dermatology. March 2009. Superficial dermabrasion in the treatment of recent stretch marks (striae rubra): http://www.jaad.org/article/S0190-9622(08)02326-8/abstract [Accessed 26.02.2018]