striae

Horizontal Linear Streaks on a Healthy Teenager’s Back

Volume 13 - Issue 6 - June 2014

Authors:
Alexander K. C. Leung, MD—Series Editor, and Benjamin Barankin, MD

Citation:
Leung AKC, Barankin B. Horizontal linear streaks on a healthy teenager’s back. Consultant for Pediatricians. 2014;13(6):262,264.

 

A 17-year-old adolescent presented with multiple transverse striae on his back. The striae were first noted 3 years ago. He had experienced quite a rapid growth spurt over the past few years, and he was active in sports.

There was no history of trauma, excessive physical exertion, or weightlifting. He was otherwise healthy and was not taking any medication. There was no family history of similar skin lesions.

skin

On physical examination, his weight was 50 kg, and his height was 172 cm. His heart rate was 64 beats/min, and his blood pressure was 115/75 mm Hg. Multiple violaceous, atrophic, horizontal linear striae were noted at the upper and lower back. All other physical examination findings were normal.

 

What’s your diagnosis?

Answer: Physiological striae atrophicae of adolescence

This patient has physiological striae atrophicae of adolescence, also known as physiological striae atrophicae of puberty.1 

Transverse linear striae on the back in adolescence were first reported by Weber2 in 1935 and then by Rosenthal3 in 1937. Weber used the term idiopathic striae atrophicae of puberty to describe this condition.2

Incidence

The exact incidence is not known. Because physiological striae atrophicae of adolescence occur mainly on the back, they are less likely to be noted by the patient or detected by a physician unless a thorough examination is performed.

In a 3-year routine screening program for scoliosis of 2,600 adolescents aged 12 to 16 years in Israel, lumbar horizontal striae were documented in 47 (1.8%) cases.4 The condition is more common in boys, presumably because boys grow faster than girls at around puberty.

The onset of striae usually is between 14 and 20 years of age in boys and 10 to 16 years of age in girls.5,6

Etiology

In the majority of cases, the etiology is not known. Typically, physiological striae atrophicae of adolescence occur in non-obese adolescents who are undergoing rapid linear growth.4 Characteristically, the striae occur at right angles to the tension of the skin or the direction of maximal tissue growth.

Pathogenesis

Historically, some cases had been attributed to dermal tearing resulting in dermal breaks in connective tissue related to the stress of repetitive weightlifting.7,8 Today it is believed that mechanical shearing and stretching of the skin does not alone cause the striae. Hormonal factors (eg, excessive cortisol level) and genetic predisposition also may be operative.1,6

Clinical Manifestations

Physiological striae atrophicae of adolescence occur mainly in healthy, non-obese individuals at around puberty in association with the adolescent growth spurt.1 The development of striae coincides with markers of adolescence such as testicular enlargement, breast development, pubic hair growth, and menarche. By definition, there is no identifiable underlying cause such as an endocrine disorder or connective tissue disorder.

Physiological striae atrophicae of adolescence typically presents as red or purple, horizontal, linear streaks (striae rubra) in the lumbar area, giving rise to a “washboard” appearance.1,6,9 Over time, the color fades, and the lesions become atrophic and silvery (striae alba). They usually are several cm long and 1 to 10 mm wide, with the long axis perpendicular to the direction of skin tension.10

Diagnosis

The diagnosis is based mainly on the characteristic clinical history and physical findings. Laboratory investigations are not necessary.

Differential Diagnosis

In contrast to physiological striae atrophicae of adolescence, lesions of striae distensae or “stretch marks” occur mainly in areas that are subject to distension, such as the lower abdomen, lateral thighs, buttocks, and breasts. The condition occurs more frequently in females, with a female to male ratio of 2.5:1.9 Striae distensae occur in association with a number of conditions such as obesity, pregnancy (striae gravidarum), prolonged use of systemic or topical corticosteroids, excessive use of marijuana, Cushing syndrome, and Marfan syndrome.11 Striae distensae also may occur after breast augmentation or intense slimming diets.12

Physiological striae atrophicae of adolescence must be differentiated from the atrophic, nonpapyraceous scars and the “cigarette paper” and crumpled scars seen in Ehlers-Danlos syndrome.13

The other differential diagnosis is linear focal elastosis, which is characterized by asymptomatic, yellow, linear, palpable, irregularly indurated, striae-like lines extending horizontally across the back.14 The condition represents an excessive regenerative process of elastic fibers and is analogous to keloidal repair of striae distensae.14

Physiological striae atrophicae of adolescence also must be differentiated from bruises resulting from accidental or nonaccidental injury. In general, physiological striae atrophicae of adolescence are not tender, do not change color over a short period of time, and may take years to fade. In contrast, bruises usually are tender and tend to fade within 2 weeks. Bruises have many more shades; the color spectrum ranges from the blue-black or purple hue of the fresh injury through the stages of hemosiderin breakdown, leading to a yellow-green color. Physiological striae atrophicae of adolescence have been mistaken for nonaccidental injury many times in the past.4,10,15-18 Thus, it is important for child care professionals to be familiar with the benign nature of this condition in order to prevent false accusations of child abuse.

Prognosis

The prognosis is good. The color tends to fade with time, and the striae will become barely visible, white-silvery, atrophic lesions with a wrinkly surface.6

Management

The condition is benign and has no medical consequences. Treatment is therefore not required other than reassurance.1 If treatment is desired for cosmesis, options include topical tretinoin and various lasers.10

 

Alexander K. C. Leung, MD—Series Editor, is a clinical professor of pediatrics at the University of Calgary and a pediatric consultant at the Alberta Children’s Hospital in Calgary.

Benjamin Barankin, MD, is medical director and founder of the Toronto Dermatology Centre.

 

REFERENCES

  1. Leung AKC, Barankin B. Physiological striae atrophicae of adolescence with involvement of the upper back. Case Rep Pediatr. 2013;2013:386094.
  2. Weber FP. “Idiopathic” striae atrophicae of puberty. Lancet. 1935;226(5851):885-886.
  3. Rosenthal DB. Striae atrophicae cutis. Lancet. 1937;229(5923):557-560.
  4. Cohen HA, Matalon A, Mezger A, Ben Amitai D, Barzilai A. Striae in adolescents mistaken for physical abuse. J Fam Pract. 1997;45(1):84-85.
  5. Basak P, Dhar S, Kanwar AJ. Involvement of the legs in idiopathic striae distensae—a case report. Indian J Dermatol. 1989;34(1):21-22.
  6. Feldman K, Smith WG. Idiopathic striae atrophicae of puberty. CMAJ. 2007;176(7):929-931.
  7. Savage J. Stria migrans. Br J Dermatol. 1965;77(8-9):472-473.
  8. Shelley WB, Cohen W. Stria migrans. Arch Dermatol. 1964;90(2):193-194.
  9. Mishriki YY. Asymptomatic ‘streaks’ in a healthy young man: adolescent lumbar striae. Postgrad Med. 2000;107(4):237-240.
  10. Burk CJ, Pandrangi B, Connelly EA. Striae. Arch Pediatr Adolesc Med. 2008;162(3):277-278.
  11. Atwal GSS, Manku LK, Griffiths CEM, Polson DW. Striae gravidarum in primiparae. Br J Dermatol. 2006;155(5):965-969.
  12. Basile FV, Basile AV, Basile AR. Striae distensae after breast augmentation. Aesthetic Plast Surg. 2012;36(4):894-900.
  13. Castori M. Ehlers-Danlos syndrome, hypermobility type: an underdiagnosed hereditary connective tissue disorder with mucocutaneous, articular, and systemic manifestations. ISRN Dermatol. 2012;2012:751768.
  14. Jang WS, Lee JW, Yoo KH, et al. Could a growth spurt cause linear focal elastosis like striae distensae? Ann Dermatol. 2012;24(1):81-83.
  15. Elshimy N, Gandhi A. A teenager with lumbar striae distensae (when a bruise is not a bruise). BMJ Case Rep. 2013 Dec 18;2013. doi:10.1136/bcr-2013-201962.
  16. Heller D. Lumbar physiological striae in adolescence suspected to be non-accidental injury. BMJ. 1995;311(7007):738.
  17. Masand M. Physiological striae in adolescence: not physical abuse. Emerg Med J. 2012;29(1):9.
  18. Robinson AL, Koester GA, Kaufman A. Striae vs scars of ritual abuse in a male adolescent. Arch Fam Med. 1994;3(5):398-399.