Evaluation of patient satisfaction and influencing factors in the treatment of striae distensae with novel growth factor-based serum

Abstract

Striae distensae, commonly known as stretch marks, are dermal scars resulting from excessive skin stretching and structural remodeling. Despite numerous treatment modalities, patient satisfaction varies significantly, and effective management remains a challenge. This study aimed to evaluate patient satisfaction with novel serum containing amino acids, vitamins, and growth factors for the treatment of striae distensae and to assess the impact of individual characteristics, lesion aspects, and patient habits on treatment outcomes. A total of 156 patients underwent MN-assisted application of the serum. Treatment frequency and duration were determined by physicians on the basis of individual response. Patients completed an online questionnaire assessing demographics, lesion characteristics, lifestyle habits, and satisfaction via the customer satisfaction score (CSAT). Data were analyzed to identify factors influencing treatment satisfaction. Overall, 82.4% of patients were very satisfied, and 78.4% reported significant improvement in striae appearance. Satisfaction was highest in younger patients (≤ 44 years), those with newer striae, and nonsmokers. Patients with medium skin tones reported greater satisfaction than did those with very fair or dark brown/black skin tones. Most patients (65%) required only one treatment session to observe improvements, and 72% noticed visible results within two weeks. Adverse effects were minimal, affecting only 8.4% of the participants. The serum demonstrated high patient satisfaction and rapid improvement in the striae distensae. Factors such as age, striae duration, smoking, and skin tone influenced treatment outcomes. These findings support the importance of personalized treatment approaches for optimal results.

Key Points

• Novel growth factor-based serum for the treatment of striae distensae.

• Patient satisfaction with the treatment of striae distansae.

• Factors influencing the treatment of striae distensae.

Introduction

Striae distensae, also known as stretch marks, are common skin conditions characterized by linear bands of atrophic skin. They often develop due to excessive stretching and structural remodeling of the dermis, which often accompanies physiological changes such as pregnancy, rapid weight gain, puberty, and prolonged use of corticosteroids [1]. When mechanical stretching leads to microtraumas, there is a restructuring of the components of the extracellular matrix (ECM), which is reflected in the striae distensae [2]. The disorganization and fragmentation of elastin fibers in combination with a decrease in collagen types I and III constitute the cascade that leads to striae [3]. Increased glucocorticoid levels can inhibit fibroblast activity and reduce ECM synthesis, contributing to thinning of the skin and an increased risk of striae [4]. Striae distensae are more common in women and are reported in 50 to 80% of women aged 5 to 50 years [1, 5, 6].

Molecular analysis of striae tissue revealed that the most differentially expressed genes are secretoglobins, which selectively interact with several steroid hormones [7]. High concentrations of steroid hormones can have a catabolic effect on fibroblasts, leading to reduced collagen deposition in the ECM and consequently reduced skin elasticity [8]. Elastin plays an important role in striae distensae, as it was the most upregulated gene in a microarray study of striae biopsies from women [7] and showed SNP association in the genome of more than 13 thousand people with striae compared with more than 20,000 people who served as controls [9]. Understanding the molecular pathways responsible for the development of striae distensae is fundamental to the development of specific therapies targeting these molecular alterations.

The treatment of striae distensae depends on the stage of the striae (early erythematous stage vs. late atrophic stage), the age of the patient and the skin type. Most treatments focus on improving the texture and appearance of the skin. Topical creams or serums, including retinoic acids, may have some efficacy, as they can stimulate collagen production and skin remodeling [10]. In addition, extracts of Centella asiatica are used for their moisturizing and repairing effects, although evidence of their success is still limited [11]. Physician-performed treatments such as lasers and microabrasion have shown significant efficacy in improving both early and mature striae by inducing neocollagenesis and elastin synthesis [12]. Microneedling is often used in combination with topical agents and has become very popular, as it promotes skin elasticity and improvement. Other modalities, such as radiofrequency and pulsed dye, target vascular and structural abnormalities in the striae [13]. Other more modern therapies include the use of growth factors and stem cell treatments [14]. Although striae are not considered a disease, the lesions can be disfiguring and affect many women psychologically and emotionally [15]. Therefore, this study aimed to evaluate the patient (customer) satisfaction score (CSAT) with serum levels of amino acids, vitamins, and growth factors and the influence of individual characteristics, aspects of the lesion, and patient habits on the CSAT.

Materials and methods

All patients were treated by licensed physicians for striae distensae with serum consisting of amino acids, vitamin B3, hyaluronic acid, growth factors (EGF, FGF and TGFb), exosomes, chlorphenesin, glycerin and water. (Nue regenerated serum, Nue Professional, Kemp House, London). Patients were first interviewed to review their medical history and check for contraindications (e.g., active skin infections, recent treatments or allergies). On the day of treatment, the affected area was first cleaned and disinfected with a medical antiseptic. To treat patients with serum, the doctor caused microdamage via a pen with a compact needle configuration that ensured that only the affected areas were treated. The needles enter the skin in a controlled, staggered pattern, which creates microscopic channels that target the exact areas of damaged skin. The serum was applied to these areas while the pen created microchannels. Another layer of serum was then applied to the treated area and allowed to dry for 10 min.

Patients received further sessions at the discretion of the doctor, with number of treatment ranging from one to six and intervals from 2 to 8 weeks. Treatment was not stopped until the skin had fully recovered.

The study was designed as a retrospective study to evaluate patient satisfaction (CSAT) in the treatment of striae. One hundred and fifty-six patients who had used the serum for this study gave their consent and voluntarily answered the questionnaire that the physician had sent to his patients via an online form. Patients were randomly selected by simple random sampling. The patients were only included in the study after the treatments had been completed. The treatments and all related aspects were decided by the doctors with the aim of achieving the best outcome in the treatment of striae. None of the decisions made during treatment benefited the study or its results. The questionnaire included multiple-choice answers related to individual characteristics, aspects of the lesion, patient habits, and patient satisfaction with treatment (Table 1).

Table 1.

Online questionnaire submitted to patients by their physicians

Question	Possible answers
What is your gender?	Female/Male/Non-binary-Other
What is your age range?	18–24/25–34/35–44/45–54/+ 55
Do you smoke?	Yes/No
How often do you exercise per week?	Never/1–2 times/3–4 times/+ 5 times
Do you drink alcohol?	No/Yes, occasionally/Yes, regularly
What is your skin color?	Very fair/Fair/Olive/Medium/Brown/Dark Brown‒Black
How old are your stretch marks	Less than a year/More than 5 years old/More than a decade
How satisfied are you with the effectiveness of the serum?	Very satisfied/Satisfied/Neutral/Dissatisfied/Very dissatisfied
How would you rate the overall appearance of your stretch marks after using the serum?	Improved significantly/Improved moderately/Slight improvement/No change/Worse
How many treatments did it take for you to see noticeable results?	1 treatment/2 treatments/3 treatments/4 or more treatments/No improvement
How quickly did you notice improvements in your skin after using the serum?	Within 1 week/Within 2 weeks/Within 1 month/Longer than 1 month
Have you experienced any side effects or discomfort from using the serum?	Yes/No
Which areas of your body did you apply the serum to?	Abdomen/Hips/Thighs/Arms/Breasts
Which other remedies have you tried to treat your stretch marks?	Topical creams/Home remedies/Microneedling/Laser treatments/Others
How satisfied were you with these other remedies compared to the serum?	Much more satisfied/Somewhat more satisfied/Equally satisfied/Less satisfied/Much less satisfied

Data were analyzed using the CSAT method according to previously described methods [16, 17]. Briefly, the analysis was based on the percentage of clients who assigned the highest scores to the evaluation. The number of highly satisfied customers in relation to the number of responses served as the basis for calculation. We also stratified the data to calculate the influence of all analyzed variables on patient satisfaction and the outcome of the Striae treatment.

Results

Overall, 82.4% of the patients were very satisfied, 6.5% were satisfied, and 11.1% were neutral. None of the patients stated that they were dissatisfied with the treatment. When asked how they would rate the overall appearance of their striae after using the serum, 78.4% responded that it had improved significantly, 8.1% reported a moderate improvement, 10.1% a slight improvement and 3.4% reported no change. None of the patients reported worsening of the appearance of the striae. Sixty-five percent of patients required only one treatment to see an improvement in the appearance of the striae, whereas 7.1% required two treatments, 17.4% required three treatments, 9% required four or more treatments, and 1.3% saw no improvement in the appearance of the striae. Seventy-two percent of patients noticed an improvement in striae in the first two weeks after treatment, 21.9% noticed an improvement in the first month, and 3.2% noticed an improvement after one month of treatment. Only 8.4% of patients reported discomfort after using the serum. The body regions treated included the abdomen (64.1%), hips (10.3%), thighs (10.3%), arms (7.7%), breasts (3.8%) and other regions (3.8%). Ninety-three percent of patients had undergone other treatments before the serum was used. Eighty-nine percent of patients were more satisfied with the serum than with the other previously used treatments (topical creams, home remedies, microneedling, laser).

An analysis of patient satisfaction, considering individual characteristics, revealed greater satisfaction in female (87.3%) and male (89.8%) patients than in nonbinary or other sex groups (57.1%; Fig. 1). The same trend was observed for patients aged up to 44 years, with a level of satisfaction of up to 94.4%, whereas it decreased to 33.3% for patients over 55 years (Fig. 2). Furthermore, satisfaction was greater when the striae were less than one year old (Fig. 3).

Fig. 1.

Patient (customer) satisfaction score (percentage) after striae distensae treatment with serum, taking sex into account. VS. very satisfied; S. satisfied; D. dissatisfied; VD. very dissatisfied

Fig. 2.

Patient (customer) satisfaction score (percentage) after striae distensae treatment with serum, taking age into account. VS. very satisfied; S. satisfied; D. dissatisfied; VD. very dissatisfied

Fig. 3.

Patient (customer) satisfaction score (percentage) after striae distensae treatment, with serum taking striae age into account. VS. very satisfied; S. satisfied; D. dissatisfied; VD. very dissatisfied

When patients'lifestyle habits were taken into account, satisfaction was greater in nonsmoking patients (90.0%) than in smoking patients (68.8%; Fig. 4). The patients’ exercise habits had no influence on their level of satisfaction; only the group of patients who exercised 3–4 times a week experienced a slight decrease (Fig. 5). The alcohol consumption of patients had no influence on their satisfaction values (Fig. 6).

Fig. 4.

Patient (customer) satisfaction score (percentage) after striae distensae treatment with serum taking smoking habits into account. VS. very satisfied; S. satisfied; D. dissatisfied; VD. very dissatisfied

Fig. 5.

Patient (customer) satisfaction score (percentage) after striae distensae treatment with serum, taking exercise habits into account. VS. very satisfied; S. satisfied; D. dissatisfied; VD. very dissatisfied

Fig. 6.

Patient (customer) satisfaction score (percentage) after striae distensae treatment with serum and alcohol consumption. VS. very satisfied; S. satisfied; D. dissatisfied; VD. very dissatisfied

In terms of skin color, satisfaction was higher in patients with light, medium and brown skin (92.9, 90.2 and 98.2%, respectively), while satisfaction decreased in patients with very light (80%) or dark brown/black skin (33.3%; Fig. 7).

Fig. 7.

Patient (customer) satisfaction score (percentage) after striae distensae treatment with serum, taking skin color into account. VS. very satisfied; S. satisfied; D. dissatisfied; VD. very dissatisfied

Discussion

The treatment of striae distensae is a demanding process that can be time-consuming and costly. The success of treatment depends on factors such as the age of the striae, skin type and individual habits. The treatment proposed here has a high patient satisfaction rate, and factors that can influence the treatment outcome have been identified.

Patient satisfaction can range from 5.4 to 95.7% depending on the treatment [18–20]. Treatments that combine microdermal abrasion with growth factors and other skin supplements tend to achieve higher improvement rates than treatments that use only topical creams or serums [19]. In this study, we achieved a satisfaction rate of 82.4%, without any of the patients expressing dissatisfaction. Another great success of the treatment proposed here is that 65% of patients needed only one treatment to achieve an improvement in the appearance of the striae. Most treatments proposed in the literature require two to six before the patient perceives an improvement [21–23]. A patient/customer satisfaction study has its limitations in self-report bias. Satisfaction is subjective and depends on the patient's perspective and expectations. In addition, the way the lesion affects the patient's self-image could influence the patient's evaluation of the outcome. However, the random selection of patients would minimize this confounding factor. Other confounding factors such as age, duration of striae, skin tone, smoking status, lifestyle factors and number of sessions were considered in the analysis. The analysis of customer satisfaction was used as a performance indicator for quality in several articles on different areas of medicine [24–26].

Patient satisfaction was influenced by patient age, with younger patients having a higher satisfaction rate. This can be explained by the fact that the skin renewal process decreases significantly with age due to a combination of factors. Cell turnover in the epidermis decreases, which leads to a thinner outer skin layer and slower wound healing [27–29]. In addition, fibroblast activity decreases, which leads to a decrease in the production of collagen and elastin [30, 31]. The success of the treatment is also influenced by the age of the striae. Stria in the early stages are characterized by increased vascularization and fibroblast activity. Fibroblasts from early striae distensae are the richest cells in alpha-smooth muscle actin filaments and produce the highest contractile forces [21, 32]. These characteristics make newer striae more susceptible to treatments aimed at cell regeneration. In contrast, mature striae exhibit atrophy of the skin, inactive or atrophic fibroblasts and a shift toward a predominance of collagen I, leading to fibrotic scarring and reduced skin elasticity [33]. This structural rigidity and loss of active cell turnover make older striae more resistant to intervention.

It is clear that smoking reduces the satisfaction of patients in this study. Extrinsically, environmental factors and daily habits can further impair the ability of the skin to regenerate [34]. Smoking causes oxidative stress; damages cellular DNA, proteins and lipids; and impairs the body’s ability to repair and regenerate tissues [35]. Research suggests that smoking inhibits the proliferation and differentiation of stem cells, which are critical for tissue repair, and disrupts the microvascular environment necessary for the delivery of nutrients and oxygen to regenerating cells [35], thereby impeding the healing of skin microinjuries caused by physicians using mechanical pens.

There was a difference in the rate of satisfaction with skin color. Patients with medium-light to medium-brown skin were very satisfied, whereas patients with dark brown/black skin had a lower satisfaction rate. The melanin content, integrity of the stratum corneum and composition of the skin can influence the recovery of the skin [36]. Histological evaluation of scars revealed that skin recovers more slowly in individuals with darker skin tone and are at greater risk for abnormal scarring [37]. In addition, the penetration of chemicals is lower in darker skin [38]. Conversely, lighter skin tones can regenerate faster and are less susceptible to inflammation [37].

Conclusion

The application of mechanical abrasion with the proposed serum resulted in high patient satisfaction with rapid improvement in the striae distensae. Moreover, factors that can influence treatment success, such as patient age, age of striae, health habits and skin color, were identified. Understanding these differences is crucial for the development of personalized approaches for the treatment of striae distensae in different populations.

Author contributions

BL conceptualized the study and wrote the main manuscript. YI carried out the procedures. MGF analyzed the data.

Funding

This study was not funded.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

All data were collected in an electronic form filled out by the patients who had consented to the study. All patients agreed to the publication of the results. The patients'results are published anonymously so that there is no possibility of identification. All methods were carried out in accordance with the relevant guidelines and regulations.

Competing interests

The authors declare no competing interests.