Stretch marks (striae) in athletes: prevention, diagnosis and when to see a doctor

Stretch marks are easier to prevent than to get rid of. But what to do if they have already appeared, and can they indicate something more serious than a cosmetic defect? The editorial team gathered evidence-based data on the prevention, diagnosis and treatment of striae in athletes and singled out the situations when stretch marks call for a doctor's visit.

Prevention: what really works

The most effective prevention of striae in athletes is not related to creams; it lies in controlling the rate of body changes. Gradual mass gain with a moderate calorie surplus gives the skin time to remodel and fibroblasts time to synthesize new collagen. A practical guideline for most athletes is to assess weight dynamics weekly and avoid sharp jumps, especially after periods of dieting or a break in training.

The second component is a gradual buildup of training volume for the 'risk' zones: chest, delts, biceps, thighs. A sharp increase in the number of sets for these muscles after a pause causes rapid swelling and hypertrophy, and therefore overstretching of the skin. The same logic applies to recovery after injuries.

As for topical agents, the evidence base is modest. The systematic review by Al-Himdani et al. (2014) and the review by Ud-Din et al. (2016) concluded that for most popular creams and oils (cocoa butter, olive oil) no convincing preventive effect has been proven. There are some data for preparations with Centella asiatica and hyaluronic acid, but they were obtained mostly on pregnant women rather than athletes.

Moisturizing and massaging the skin do no harm and can improve its elasticity and comfort, so there is no need to give them up. It is just worth understanding: a cream does not compensate for gaining a dozen kilograms over a few months.

• monitor the weekly dynamics of body mass;
• build up the volume of training for the 'risk' zones gradually;
• ensure sufficient intake of protein and micronutrients;
• avoid prolonged self-directed use of corticosteroid ointments;
• refuse hormonal drugs without medical indications.

How to recognize striae and distinguish them from other skin changes

A diagnosis of striae is usually made clinically, during examination. The dermatologist assesses the color, width, depth, localization and symmetry of the lines, and also finds out when they appeared and what preceded it. Laboratory or instrumental studies are not needed for typical cases.

Fresh striae (striae rubrae) are pink or purple, may itch and protrude slightly. Mature ones (striae albae) are whitish, sunken, with a thin surface. This difference is fundamental for treatment: most methods are much more effective specifically at the early, 'red' stage, when inflammation and remodeling are still ongoing in the dermis.

Sometimes other conditions are mistaken for stretch marks: linear scars after injuries, skin atrophy from corticosteroid injections, linear pigment changes. In unclear cases a doctor may use dermatoscopy and, rarely, a biopsy. For an athlete it is important to show the specialist all areas and honestly report drug use.

A separate situation is striae that look 'atypical': very wide (over a centimeter), dark crimson, located on the abdomen and thighs and combined with other changes in the body. In such a case the doctor will definitely consider an endocrine cause.

When striae are a reason for examination

In most athletes striae have an obvious explanation: rapid mass gain or hypertrophy. However, there are situations when stretch marks can indicate a systemic problem. The most important of them is endogenous or iatrogenic hypercortisolism (Cushing's syndrome). The endocrinology guidelines by Nieman et al. (2008) attribute wide crimson striae to the signs that best distinguish Cushing's syndrome from ordinary obesity.

Warning signs include a combination of striae with fat gain mainly on the trunk and face, weakness of the thigh muscles (difficulty rising from a squat without using the hands), a tendency to bruise, and elevated blood pressure or blood sugar. Athletes sometimes write these symptoms off as overtraining, but they require examination.

The second group is drug use. If striae appeared against a background of prolonged corticosteroid treatment or the use of hormonal agents, the doctor may suggest assessing the hormonal background, lipid profile, blood pressure and blood counts. Stretch marks here are only the visible marker of a broader picture.

The third is signs of hereditary connective-tissue disorders: striae with no obvious cause combined with joint hypermobility, frequent dislocations and features of body build. In such cases a consultation with a geneticist or cardiologist is appropriate, since some of these conditions affect the heart and aorta.

Treatment methods: from creams to lasers

It is impossible to remove striae completely; any treatment is aimed at making them less noticeable. Realistic expectations are the key to satisfaction with the result. The methods work best on fresh, red striae, so it is worth seeing a dermatologist as early as possible.

Among topical agents, the most data concern tretinoin (a prescription retinoid): in a number of studies it reduced the length and width of fresh striae. The reviews by Elsaie et al. (2009) and Ud-Din et al. (2016) note that the effect on mature striae is much weaker. Tretinoin is contraindicated during pregnancy and can irritate the skin, so it is prescribed by a doctor.

Device-based methods include the pulsed dye laser (reduces the redness of fresh striae), fractional lasers, microneedling therapy and radiofrequency techniques that stimulate collagen remodeling. According to reviews, fractional technologies give a moderate improvement in the texture of mature striae but require several sessions and carry a risk of pigmentation, especially on darker skin.

For an athlete it is important that after most device-based procedures a pause in intense training and protection of the skin from friction and sun are needed. Plan such procedures for a period of reduced load, for example the off-season.

Practical advice for the athlete

If striae have already appeared, the first thing to do is to analyze the cause. Was there a sharp mass gain? Did the training volume change? Were any drugs used? The answers will help avoid new stretch marks and, if necessary, see a doctor in time.

At an early stage, make an appointment with a dermatologist: this period is the most favorable for treatment. Do not use strong corticosteroid creams 'for itching' without a prescription; they themselves thin the skin and can worsen the situation.

For mature striae, cosmetic agents and massage only improve the overall condition of the skin. If the stretch marks bother you significantly, discuss device-based methods and a realistic result with a dermatologist. A tan makes striae more noticeable, since scar tissue tans worse, so it is worth using sunscreen.

For a deeper understanding of the topic we recommend reading our materials on the causes of striae and their link to training load and pharmacology, on controlled mass gain and on the side effects of corticosteroids in sports medicine.

Editorial conclusions

Striae are scarring changes of the skin that are best prevented by controlling the rate of mass gain and by gradually building up training. Creams and oils have a weak evidence base for prevention, although moisturizing the skin does no harm.

Diagnosis is mostly clinical. Wide crimson striae combined with fat gain on the trunk, weakness, elevated blood pressure or appearance against a background of hormonal drugs are a reason to see a doctor and rule out endocrine disorders.

Treatment (tretinoin, lasers, microneedling) works best on fresh striae and reduces their visibility but does not remove them completely. The method should be chosen together with a dermatologist.

References

1. Al-Himdani S, Ud-Din S, Gilmore S, Bayat A. Striae distensae: a comprehensive review and evidence-based evaluation of prophylaxis and treatment. Br J Dermatol. 2014;170(3):527–547.
2. Ud-Din S, McGeorge D, Bayat A. Topical management of striae distensae (stretch marks): prevention and therapy of striae rubrae and albae. J Eur Acad Dermatol Venereol. 2016;30(2):211–222.
3. Elsaie ML, Baumann LS, Elsaaiee LT. Striae distensae (stretch marks) and different modalities of therapy: an update. Dermatol Surg. 2009;35(4):563–573.
4. Nieman LK, Biller BM, Findling JW, et al. The diagnosis of Cushing's syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2008;93(5):1526–1540.
5. Watson RE, Parry EJ, Humphries JD, et al. Fibrillin microfibrils are reduced in skin exhibiting striae distensae. Br J Dermatol. 1998;138(6):931–937.
6. Pope HG Jr, Wood RI, Rogol A, et al. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev. 2014;35(3):341–375.