Striae are extremely common and often cause cosmetic morbidity and psychological distress, particularly in women and certain professions. However, despite several advances, no fully effective treatment has emerged (1).
Up to our best Knowledge, this is the first study to treat striae with MN combined with IACM gel compared to MN alone. There was a significant difference regarding degree of improvement in which better improvement was detected in the right side. Also, the improvement of striae was earlier in the right side than the left side. This improvement was documented and proved by the histopathological staining by Hematoxyline and eosin (H&E), Masson trichrome and Orcein stain. In the right side, 10% had mild improvement, 40% had moderate improvement, 25% had marked improvement and 25% had excellent improvement. While in the left side, 15% had mild improvement, 45% had moderate improvement, 30% had marked and 10% had excellent improvement
In line with our findings, Nassar et al., (2016) (11) showed in all the patients who were treated with needling therapy, 18 from 20 (90%) patients were improved. 6 (30%) were excellent, 8 (40%) were good, and 2 (10%) were moderately improved; 2 (10%) were mild however, 2 (10%) did not show any improvement after the treatment. However, the results of the current study was better as all patients were improved
In accordance to the current results, Alster et al., (2020) (12) described the clinical results and side effects of MN in a series of 25 individuals with SD. Patients received 1 to 3 consecutive monthly treatments. All striae improved at least 50% after an average of 2 treatment sessions, and 28% of patients demonstrated more than 75% clinical improvement.
Also, Khater et al., (2016) (13) involved twenty Egyptian female patients with striae in the abdomen and lower limbs. The patients were treated with needling therapy and CO2 fractional laser every 1 month for 3 sessions. Clinical improvement was assessed by comparing photographs and patient’s satisfaction before and after treatment. Their result revealed that in the needle-treated patients the global photographs showed 9 from 10 (90%) patients were improved. Among the 10 patients, 3 (30%) had good, 4 (40%) had fair, and 2 (20%) had poor improvements; however, 1 (10%) did not show any improvement after the treatment. In CO2 FL-treated group, 5 of the 10 patients (50%) showed clinical improvement, of them 1 (10%) were good, 3 (30%) were fair, and 1 (10%) were poor improvements. However, 5 patients (50%) did not show any improvement after the treatment. By comparing this result with our result, our findings showed more improvement than CO2 fractional laser therapy.
Furthermore, Hodeib et al., (2017) (14) included 20 patients with striae alba. Every patient received treatment in the form of PRP injection in their right side (group A) and carboxytherapy session in their left side (group B) every 3-4 weeks for 4 sessions. They concluded that both methods were effective in treatment of striae. Response grading scale in group A was mild in 4(20%) patients, moderate in 10(50%) patients, marked in 5(25%) patients and excellent in 1(5%). Response grading scale in group B mild in 3(15%) patients, moderate in 12(60%) patients, marked in 3(15%) patients and excellent in 2(10%). Our result showed more improvement than PRP injection methods.
In the present study, the reported side effects were presented as erythema, pain and hyperpigmentation at the site of MN. All patients suffered from erythema and pain while hyperpigmentation was reported in 7 patients who had skin type 4, so they were more liable to post eruptive hyperpigmentation. Post eruptive hyperpigmentation was treated and resolved after 4 weeks. These complaints occurred in both sides, and they were mainly due to MN technique.
Also, Nassar et al., (2016) (11) documented that there was no significant long lasting adverse effect except transient mild erythema and post inflammatory pigmentation. In addition, Khater et al., (2016) (13) reported that the only side effects were transient mild erythema and post-inflammatory pigmentation.
In their study, Alster et al., (2020) (12) noted that side effects were limited to transient erythema in all skin phototypes. One patient experienced transient purpura after each of the 2 MN sessions. No infection or dyspigmentation was observed in any patient may be due to lower depth and number of passes.
There was statistically significant relation between the type of striae and degree of improvement in which better improvement was reported with striae rubra in right side. Regarding left side, there was no significant relation between type of striae and degree of improvement.
In agreement with our study, Ali et al., (2016) (15) showed that the relation between clinical efficacy and type of SD, in group I (treated with MN) . They reported that a statistically significant improvement was found in patients with striae rubra than striae alba who were treated by needling or microdermabrasion.
The basis of MN relies on physical trauma. It was proposed that the trauma generated by needle penetration in the skin induces regeneration of the dermis. The needles penetrate the stratum corneum and create small holes known as micro-conduits with minimal damage to the epidermis. This sequentially leads to the generation of growth factors that stimulate the production of collagen and elastin in the papillary layer of the dermis (16).
The natural wound healing cascade is induced as platelets and
neutrophils are recruited to release growth factors such as TGF-alpha, TGF beta, and PDGF. The needles also break down the old, hardened scar strands and allow it to re-vascularize. Neovascularization and neocollagenesis are initiated by migration and proliferation of fibroblasts and laying down of intercellular matrix (17).
Micro-needling enhances the delivery of various drugs across the skin barrier as it bypasses the stratum corneum and deposits the drug directly up
to the vascularized dermis. It has also been shown to cause a significant widening of the follicular infundibulum by 47%, which may partly explain the increased penetration of the medication across the skin barrier. In addition, it removes the scales and sebum residues in the neighborhood of the infundibulum (18).
The amniotic membrane is an immune-privileged tissue as it contains some immunoregulatory factors, such as HLA-G, which is an immunosuppressive factor, and the Fas ligand. This effect is also supported by the low/absent level of expression of HLA class I molecules
and the absence of HLA class II molecules (19). Several growth factors are produced by it such as EGF, keratinocyte growth factor (KGF), hepatocyte growth factor (HGF), VEGF, PDGF, asic fibroblast growth factor (bFGF), and macrophage colony-stimulating factor (M-CSF) (20).
Amniotic membrane has an anti-inflammatory effect which expresses various antiangiogenic and anti-inflammatory proteins such as the (IL)-1 receptor antagonist, tissue inhibitors of metalloproteinase (TIMPs)-1, -2, -3, -4, and IL-10. Amniotic membrane cells may exert an anticancer effect, mainly explained by the antiangiogenic, proapoptotic, and immunoregulatory activities of amnion. It reduces protease activity via the secretion of tissue inhibitors of TIMPs and downregulates the expression of transforming growth factor-beta (TGF-β), which is responsible for the activation of fibroblasts, thereby inducing an antifibrotic effect (21). Amniotic membrane is also known to exert an antimicrobial effect and, therefore, protects the wound from infection. The antibacterial effect of it can be illustrated by its expression of natural antimicrobial molecules such as β-defensins and elafin (22).
Recently, Amniotic membrane has been widely used in ophthalmology as a biological dressing over areas of ocular chemical burns, infectious/noninfectious ulceration, necrosis, or other causes of severe inflammation. It promotes keratinocyte proliferation and differentiation by releasing various growth factors. The AM markedly reduces the levels of pain and discomfort experienced by the patient when used as a biological dressing and has anti-inflammatory, anti-scarring and anti-angiogenic effects. Recently, it was used in rejuvenation , treatment of resistant ulcers, psoriasis with variable degrees of success (23,24).