Journal of Clinical & Experimental Dermatology Research
Open Access

Infected Edematous Striae Distensae

Salma Ahmad Almashat^* and Alanoud Adas ^*Correspondence: Salma Ahmad Almashat, Department of Clinical Dermatology, King Abdulaziz University, Jeddah, Saudi Arabia, Email:

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Introduction

Skin stria usually has different contributing factors, and the use of steroids can result in the appearance of large striae [1,2]. Bullous striae distensae is a condition which describe the distention of these stria as a result of fluid accumulation [3]. Striae distensae has other complications as it could get ulcerated, edematous, emphysematous and urticated [4], however, the bullous striae have not been commonly reported [3]. Physicians are usually worried about the appearance of this condition which does not need specific management other than reassurance [3]. However, in this special case, the management is different.

Case Report

A 13-year-old girl was admitted to the hospital for anasarca and diagnosed to have nephrotic syndrome. She was discharged later and enalapril, prednisolone, cyclosporin and hydroxychloroquine were prescribed. Two days after discharge she presented to the ER with worsening edema, difficulty in speaking and breathing with swollen lips and conjunctiva. She was diagnosed with angioedema and intubated. Upon history taking, the mother confirmed that her daughter has been complaining of abdominal pain for two days. On abdominal examination, there was diffused redness and abdominal distention. She also had striae over the lower abdomen and upper thighs. The striae of her abdomen were fluid filled and tense (Figure 1). On palpating the abdomen, it was very tender. Her condition was diagnosed as bullous striae distensae, and as recommended from previous literature, reassurance is the management of choice as this condition clears when the anasarca resolves [1]. However, in this special case, the bullous striae are remarkably tender, and such presentation for bullous striae distensae have not been reported in the literature. Monitoring the signs for sepsis was advised and within few hours her WBC and D-Dimer started to increase. Amoxicillin 1 gram BID was immediately started. Two days after starting the antibiotic the redness and the tenderness of her abdomen disappeared (Figure 2). However, when the patient was closely examined, one of the bullous striae was ruptured and oozing watery fluid. This could have been the main source of infection which led to the abdominal redness and tenderness. Covering the wound with aseptic technique was recommended.

Figure 1: The appearance of the abnormal stria with red discoloration as a sign of infection.

Figure 2: 2 days after treating an infected stria with antibiotics, no more redness. Arrow shows site of a ruptured stria.

Results

Perforation and infection can be a major complication of bullous stria and conservative management is not always the best choice. Also, looking for signs of inflammation and inflammatory markers could be the key to the best approach for such patients.

Discussion

It has been documented that the striae result from the force of the distention on the abdominal skin [1]. Anasarca that results from nephrotic syndrome along with use of steroids can be precipitating factors for the resultant bullous stria, as steroids are a major cause for the appearance of striae on the body [1]. These striae are different from the normal skin as there is less hydration within the dermis and epidermis along with the reduced elasticity and dermal echo density [5]. The accumulation of fluid within the striae could be due to the its weak tensile strength and the larger the stria, the more likely the accumulation of fluid occurs [1]. The appearance of such distended stria with fluids might worry dermatologists and physicians and rush them to start unnecessary measures, and therefore educating physicians about this phenomenon and the nature of the striae especially when handling patients with fluid overload is essential [1]. Generally, the striae distensae has atrophic epidermis and loss of connective tissue within in the dermis, and it is very difficult to treat it [6]. Lokhande et al. suggest controlling the cause that leads to the edema which could be heart failure, protein losing enteropathy, nephrotic syndrome or hypoalbuminemia [2]. This case enhances the importance of examining the patient for tenderness and a ruptured stria. For instance, history of oozing is suggestive of a ruptured stria. These are important questions and clinical data to detect the risk of infection or an active infection. However, there is still the question of whether to perform ascitic therapeutic tapping for patients with a ruptured stria to prevent infection or reinfection, or to choose conservative management by covering the wound and monitor signs of infection. In addition, this case reports this phenomenon in a patient with captopril induced angioedema, and as it is a commonly given medication to patients with nephrotic syndrome [7], understanding the role of angioedema on distending and rupturing the fragile stria needs furthers studies. Furthermore, regarding preventing such event, apparently depends on the ability to prevent and treat the striae which is clearly not yet available.

Conclusion

Bullous striae distensae is a condition that occurs due to massive fluid distention of large stria and there is a risk of potential rupture and infection that needs careful inspection. For the future, effective ways to treat and prevent the striae distensae are needed in order to prevent such complications.

Conflict of Interest

The authors declare no conflict of interest.

References

1. Seshadri D, Rathi M, George J, Kanwar AJ. Fluid within striae: An unusual phenomenon. J Case Rep. 2013;3(2):331-333.
2. Lokhande AJ, Dhali TK, Chaudhary P, Goel R, Rathore S. Distended striae distensae in a patient with nephrotic syndrome. J Derm Dermatol Surgy. 2018;22(2):82.
3. Masood S, Jalil P, Naveed S, Kanwal S. Bullous striae distensae with prolonged steroid use: An unusual clinical presentation. Indian Dermatol Online J. 2020;11(2):280-281.
4. Ross NA, Ho D, Fisher J, Mamalis A, Heilman E, Saedi N, et al. Striae distensae: Preventative and therapeutic modalities to improve aesthetic appearance. Dermatol Surg. 2017;43(5):635-648.
5. Cho C, Cho E, Kim N, Shin J, Woo S, Lee J, et al. Biophysical properties of striae rubra and striae alba in human skin: Comparison with normal skin. Skin Res Technol. 2019;25(3):283-288.
6. Borrelli MR, Griffin M, Ngaage LM, Longaker MT, Lorenz HP. Striae Distensae: Scars without Wounds. Plast Reconstr Surg. 2021;148(1):77-87.
7. Lombel RM, Hodson EM, Gipson DS. Treatment of steroid-resistant nephrotic syndrome in children: New guidelines from KDIGO. Pediatr Nephrol. 2013;28(3):409-414.