Evidence-based answers from the Family Physicians Inquiries Network clinical inquiries

Jeanne Moore, MD; Gary Kelsberg, MD Do any topical agents help Valley Family Medicine Residency, Renton, Wash prevent or reduce stretch marks? Sarah Safranek, MLIS University of Washington Health Sciences Evidence-based answer Libraries, Seattle

Assistant EDITOR Evid encnoe-bas topicaled answ agenter has been extract, vitamin E, and collagen hydroly- Jon O. Neher, MD A proven to prevent or reduce stretch sates doesn’t prevent new stretch marks Valley Family Medicine marks. Randomized controlled trials but might avoid additional stretch marks in Residency, Renton, Wash (RCTs) show that cocoa butter doesn’t pre- women who had already developed them vent stretch marks (strength of recommen- during puberty. Massage with vitamin E dation [SOR]: A, 2 RCTs); neither does olive ointment alone may reduce the number of oil (SOR: B, 1 small RCT). stretch marks (SOR: C, 2 small RCTs with A cream containing Centella asiatica methodologic flaws).

Evidence summary olive oil massage with no treatment in 70 nul- Two double-blind RCTs that compared cocoa liparous women beginning at 18 to 20 weeks’ butter with placebo to prevent stretch marks gestation found no reduction in stretch in pregnant women found no difference. marks (45.7% vs 62.9% without olive oil mas- In the first, investigators enrolled 300 Afro- sage; P=.115). The investigators didn’t report Caribbean women at 12 to 15 weeks’ gesta- whether they performed a sample-size analy- tion. Women used either 25% cocoa butter sis to determine if the study was adequately cream or a placebo cream comprised of emol- powered to demonstrate no difference.3 lients and vitamin E daily. Investigators moni- tored compliance and assessed stretch marks Mixed, but mostly negative, results using a validated scale at 26 weeks, 36 weeks, for multi-ingredient cream and after delivery. Cocoa butter cream didn’t A double-blind RCT found that Trofolas- reduce stretch marks (44% vs 55% for placebo; tin cream containing Centella asiatica (also P=.09). Three women (1 using cocoa butter, known as Gotu kola, a member of the pars- 2 using placebo) discontinued the cream be- ley family), vitamin E, and collagen hydroly- cause of mild self-limiting reactions.1 sates didn’t prevent pregnancy-related stretch In the second RCT, investigators ran- marks among 80 women who applied the domized 210 nulliparous women (mainly treatment beginning at 12 weeks’ gestation. with intermediate skin color) to use cocoa When investigators evaluated a subgroup butter lotion with vitamin E or placebo. Wom- of 18 women who had already developed en applied the lotion daily to their abdomen, stretch marks during puberty, they found breasts, and thighs, starting at 12 to 18 weeks’ that fewer of the women acquired additional gestation. Investigators assessed the severity stretch marks during pregnancy (11% vs 100% of stretch marks either at delivery or post- with placebo; P=.0001). The investigators partum using a validated scale. Cocoa butter didn’t calculate whether the sample was large lotion didn’t prevent stretch marks (45.1% vs enough to prove a significant difference.4 48.8% for placebo; P=.730).2 Fewer stretch marks with vitamin E Save the olive oil for cooking in small flawed study A nonblinded RCT that compared twice-daily An older systematic review (1996) included a

jfponline.com Vol 61, No 12 | December 2012 | The Journal of Family Practice 757 clinical inquiries

prospective RCT that randomized 50 women Visit us @ at 20 weeks’ gestation to massage their abdo- men, thighs, and breasts with vitamin E oint- jfponline.com ment or perform no massage. The trial found fewer stretch marks with vitamin E ointment massage (odds ratio=0.26; 95% confidence interval, 0.08-0.84). The authors of the review described this RCT as poorly randomized and without blinding; investigators didn’t report Practical guidance whether the sample size was adequate to dem- for panic disorder 5 onstrate a significant effect. Boadie W. Dunlop, MD, MSCR

4 ways to listen to Recommendations this audiocast:

The American Congress of Obstetricians and . 1. Go to jfponline.com Gynecologists Web site states that although 2. Visit www. many creams, lotions, and oils on the market myjfpmobile.com/1212 claim to prevent stretch marks, no proof ex- 3. Scan this QR code to ists that these treatments work. Using a heavy listen to the No topical moisturizer may help keep skin soft, but it audiocast on your agent—including won’t help get rid of stretch marks.6 smart phone cocoa butter and The American Academy of Dermatology 4. Text “PANIC” to olive oil—has Web site also says that a moisturizer can im- 25827 from your mobile phone and been proven prove the appearance of stretch marks and re- follow the prompt. to prevent or duce itchiness; sunless tanning products can reduce stretch hide the marks.7 JFP marks. INSTANT poll References Which occupational risk factors do you 1. Buchanan K, Fletcher HM, Reid M. Prevention of striae gravidarum with cocoa butter cream. Int J Gynaecol Obstet. find most often in patients with carpal 2010;108:65-68. tunnel syndrome? 2. Osman H, Usta IM, Rubeiz N, et al. Cocoa butter lotion for prevention of stretch marks: a double-blind, randomized and placebo-controlled trial. BJOG. 2008;115:1138-1142. 3. Taavoni S, Soltanipour F, Haghani H, et al. Effects of olive oil on striae gravidarum in the second trimester of pregnancy. Complement Ther Clin Pract.2011;17:167-169. Online exclusive 4. Mallol J, Belda MA, Costa D, et al. Prophylaxis of striae gravi- • The refugee medical exam: darum with a topical formulation. A double blind trial. Int J Cosmet Sci. 1991;13:51-57. What you need to do 5. Young GL, Jewell D. Creams for preventing stretch marks in pregnancy. Cochrane Database Syst Rev. 2000;(2):CD00066. 6. Skin Conditions During Pregnancy. The American College Photo rounds Friday  of Obstetricians and Gynecologists. Available at: www.acog. org/~/media/For%20Patients/faq169.pdf?dmc=1&ts=201203 Test your diagnostic skills. 14T1222535345. Accessed April 20, 2012. 7. Mom and baby skin care. American Academy of Dermatology. Available at: www.aad.org/media-resources/stats-and-facts/ Physician’s Briefing News  prevention-and-care/mom-and-baby-skin-care. Accessed April 20, 2012. Today’s headlines in family practice

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