Dermatologic Physical Exam

Primary Lesions

Parallel linear patches of discolored or white depressed skin (see Photo 50).

Secondary Lesions

Yellow papules of herniated adipose tissue in the base of the stretch mark beneath the epidermis. Although usually primary lesions, here papules may occur as secondary lesions.

Distribution

Microdistribution: None.

Macrodistribution: Striae of puberty occur on the thighs and lumbosacral regions in boys. In girls, they occur on the thighs, buttocks, breasts, and upper posterior calves (see Figs. 9,10). Striae of pregnancy are distributed over the lateral abdomen, hips, thighs, and breasts (see Fig. 11). Striae secondary to prolonged lifting or stretching during exercise

Drawing Dermatology Lesions
Figure 9: Macrodistribution of striae of puberty in boys.
Boys Puberty Physical Exam
Figure 10: Macrodistribution of striae of puberty in girls.

are common over the lower back and are perpendicular to the gluteal cleft (see Fig. 12, Photo 50). Striae of endocrinopathy or from systemic corticoids involve similar areas but are usually individually longer, wider, and more extensive (see Photo 51). Striae induced by potent topical steroids or occlusive therapy are local at the site of application, and may be asymmetric (see Photo 52).

Configuration

Parallel linear lesions. Striae of endocrine origin may also have a fan-like configuration.

Indicated Supporting Diagnostic Data

When physical findings and history suggest a possible endocrinopathy, the patient should be appropriately tested. The most reliable screen is a dexamethasone suppression test. Alternative tests include 8 am and 4 pm serum cortisol determinations, or a 24-hour urinary free cortisol.

Fat Swelling Process After Liposuction

Figure 11: Macrodistribution of striae of pregnancy.

Therapy

Prevention

When possible, warn susceptible patients about, and advise how to eliminate, provoking causes. In adolescent patients, use systemic and topical corticosteroids with great caution. Avoid use of the more potent fluorinated topicals, and use them sparingly over skin regions that are prone to striae formation.

Topical Tretinoin

Uncontrolled reports of cosmetic benefit from applications of topical 0.1% tretinoin cream have been published. Results are encouraging following experience with only a few patients. Double-blind studies with photographic controls are needed. Early experience would suggest this is worth trying, as there is no other effective treatment. Tretinoin should not be used during pregnancy or breastfeeding.

Figure 12: Macrodistribution of striae secondary to lifting or stretching.

Conditions That May Simulate Striae Distensae

None.

ANSWERS TO CLINICAL APPLICATION QUESTIONS

History Review

An obese, middle-aged, diabetic woman presents with a complaint of worsening stretch marks over the past year. She gives a history of marginal blood pressure readings in the past, but has never been on medication for hypertension. Exam reveals numerous wide purple-red stria beneath the breasts, in the folds of her panniculus, and on the proximal thighs just distal to the inguinal creases.

1. What underlying causes should be of concern regarding her stria?

Answer:

a. Rapid weight gain.

b. Pregnancy.

c. Systemic or local corticosteroid therapy.

d. Underlying endocrinopathy, e.g., Cushing's disease or syndrome.

2. History reveals stable weight for 5 years, no recent pregnancy, no history of systemic steroid therapy, and normal wound healing. The patient was diagnosed with intertriginous monilia 12 months ago by another practitioner, and was given a refillable prescription for a potent antiyeast/steroid cream, which she has continued to use. What is the most likely cause of her stria?

Answer: Iatrogenic stria from prolonged used of a potent topical corticosteroid.

3. What laboratory data are indicated?

Answer: There is enough reason in this patient to warrant screens for adrenal hypersecretion, despite the history of topical corticoid usage.

4. What is the appropriate treatment?

Answer: Stop the topical steroid and consider treatment with a topical retinoid.

5. What should the patient be told regarding the appearance of her stria? Answer: The stria will fade, soften, and become less noticeable. They will never completely disappear.

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