Original Contribution

Journal of Cosmetic Dermatology, 0, 1--7

An efficacy and safety of nanofractional radiofrequency for the

treatment of striae alba
Napatthaorn Pongsrihadulchai, MD, Thep Chalermchai, MD, PhD, Suwirakorn Ophaswongse, MD,
Suriya Pongsawat, MD, & Montree Udompataikul, MD
Skin Center, Srinakharinwirot University, Wattana, Bangkok, Thailand

Summary Background Striae distensae (SD) is a form of dermal scar. A number of treatments
have been proposed, but they usually have unsatisfactory result especially in striae
alba. Recently, nanofractional RF has been developed. Its mechanism of action is to
stimulate dermal remodeling and epidermal re-epithelization.
Aim To evaluate the efficacy and safety of nanofractional RF in the treatment of
striae alba.
Patients/Methods This is an experimental, assessor-blinded, beforeafter study. Thirty-
three subjects, with striae alba on their thighs, abdomen, or buttocks (11 subjects
each) were enrolled. Treatments with nanofractional RF were undergone for a total
of three sessions at 4-week intervals. Clinical outcomes were assessed, by comparing
pre- and post-treatment measurement of total lesional surface area (using digital
PictzarTM software), and length and width of lesions. Histopathological evaluation was
also performed.
Results At 4 weeks after the last treatment, the total surface area, and the width and
the length of striae alba significantly decreased from the baseline (P < 0.001).
Postinflammatory hyperpigmentation was reported in six subjects. Regarding
histopathology, the average mean number of collagen and elastin bundles was
significantly increased (P = 0.005 and 0.012, respectively).
Conclusion Nanofractional RF is highly effective with a good safety profile for the
treatment of striae alba.
Keywords: striae alba, fractional radiofrequency, nanofractional RF

atrophic change.1,2 Although this condition will

Introduction
Striae distensae (SD) is a common dermatologic
condition. There are two stages of SD which are an
early stage called striae rubra and a late stage called
striae alba. The striae rubra appears as red to vio-
laceus raised lesion while the striae alba (SA) appears
as whitish skin scarring with epidermal thinning or
Correspondence: Montree Udompataikul, Director, Skin Center, Srinakhar-
inwirot University, 114, Sukhumvit23, Klongtoeynua, Wattana, Bangkok
10110, Thailand. Emails: Umontree@gmail.com, Umontree@yahoo.com
Accepted for publication September 19, 2016
rarely cause any significant medical problems, aes-
thetically it can cause a great psychological impact
on affected patients. Striae distensae usually occurs
after rapid growth by progressive increase in weight
and height in childhood and early adolescence, mus-
cle mass hypertrophy, or during pregnancy.2 Addi-
tionally, it can be a result of high levels of
corticosteroid hormones.3 Histopathological change in
striae alba shows skin flattening of the rete ridges
and thinning epidermis.4 And also with decrease in
dermal thickness and upper dermis, thin collagen
bundles was observed.5 Furthermore, there is a

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Nanofractional RF for the treatment of striae alba . N Pongsrihadulchai et al.
reduction in collagen and elastin counts with frag-
mentation of elastin.6
Treatment modalities for SD such as topical retinoids,
chemical peeling, or microdermabrasion have been
advised, but the results are usually disappointing and
inconsistent especially for striae alba. Although some
studies have proved that fractional laser photothermol-
ysis was effective for the treatment of SD,79 hyperpig-
mentation after laser treatment is a major concerning
issue, especially in patients with darker skin.10,11
Therefore, the treatment for striae alba still remains
challenging because of the limiting outcome. Currently,
a new concept of fractional radiofrequency for facial
treatment had been approved by USFDA as skin resur-
facing.12 This novel technology has shown beneficial
effects with lower adverse effects on skin photorejuve-
nation, facial wrinkles, and acne scars.1116 Moreover,
in contrast to lasers, the RF does not essentially require
any chromospheres to target on skin, and then, this
concept can be used in all skin types.17
Recently, a novel device called nanofractional
radiofrequency (RF) has been developed for skin reju-
venation treatment. Previous clinical studies demon-
strated clinical improvement for treating several skin
conditions such as acne scar, photoaging, and textural
irregularity.18,19 This technology uses needles as the
electrode to deliver the RF energy directly to the skin
with fractionation technique.18 Due to the smaller pin
size, this new device can reduce side effect and recov-
ery time.18,19 Regarding striae, a form of dermal scar-
ring, we hypothesized that nanofractional RF may be
effective. Because of lack of evidence to confirm this
hypothesis, this study aimed to determine efficacy and
safety of nanofractional radiofrequency for the treat-
ment of striae alba.
Materials and methods
This is an assessor-blinded, before and after compara-
tive study, carried out at Skin Center, Srinakharinwirot
University, which was approved by Institutional, Clini-
cal Research Ethical Committee. Thirty-three subjects,
aged between 18 and 60 years, with Fitzpatricks skin
types III-IV, diagnosed with striae alba, confirmed by
dermatologists, with lesional sites located on thigh,
abdominal, or buttock area (11 subjects per site) were
enrolled in this study. The prominent visible lesions
were selected and assigned to be treated with nanofrac-
tional RF (Venus VivaTM, Toronto, Canada) for three
sessions at 4-week intervals. This device delivered the
RF energy solely through 160 pins per tip, with a
maximum energy of 62 millijoules per 1 pin with
2 2016 Wiley Periodicals, Inc.
150 9 20 microns per pin size.19 Energy protocol was
delivered at 220 volts with pulse duration of 20 mil-
liseconds for two passes. Prior to the procedure, anes-
thetic cream (2.5% lidocaine/2.5% prilocaine) was
applied under occlusive dressing for 60 min.
The subjects were followed up for four visits every 4-
week interval at weeks 4, 8, and 12. Serial photo-
graphic examination was taken with a high-resolution
camera (Olympus XZ10, Tokyo, Japan) before and after
treatment with the same setting. Clinical outcomes
were assessed for pre- and postcomparison, for total
lesional surface area (evaluated digitally by PictzarTM
software, Biovisual Technologies, New Jersey, USA20),
and the length and width of striae (caliper measure-
ment). Additionally, subjects satisfactions for the
change in lesional texture, size, and overall improve-
ment were also evaluated using 5-rating score. The
patients 5-score rating scale is as follows; 1 = very dis-
satisfied, 2 = not very satisfied, 3 = slightly satisfied,
4 = satisfied, and 5 = very satisfied. Physicians satis-
faction score to compare before and after treatment by
photographs had been determined by two independent-
blinded dermatologists using clinical quartile rating
scale. The quartile rating scale is as follows: 0 = 0
25% improvement, 1 = 2650% improvement, 2 =
5175% improvement, and 3 = 75% improvement.
Adverse effects and pain score (numeric rating scale)
were also determined. Skin biopsy with histologi-
cal examination for skin epidermal thickness, and
collagen and elastin counts were evaluated for six sub-
jects (two specimens for each specific area) at baseline
and 12-week visit. The skin specimens were obtained
by 3-mm punch biopsy and stained with hema-
toxylin and eosin, Masson trichrome, and Verhoeff Van
Gieson.
Inclusion criteria
The subjects, aged between 18 and 60 years, with skin
type III or IV were diagnosed with striae alba at thigh,
abdominal, or buttock area.
Exclusion criteria
Subjects who were previously treated with any kind of
lasers, RF, dermabrasion, microdermabrasion, or chem-
ical peeling within 6 months prior to the study; sub-
jects who applied topical corticosteroids, retinoid,
vitamin C, or vitamin E within 3 months; subjects who
orally took any of the following supplement or medica-
tions such as vitamin C, vitamin E, corticosteroids,
or retinoids within 3 months; subjects who is a
 Nanofractional RF for the treatment of striae alba . N Pongsrihadulchai et al.

heavy tobacco smoker; subjects who had a history of Table 1 Baseline demographics
hypertrophic scar or keloid; subjects who is on pace-
Results
maker or have other metallic implants; and subjects
Demographic data (n = 33)
who have active skin lesions on RF-treated area were
excluded. Age, mean (SD) (years) 28 (8.58)
Age, range (years) 1954
Duration of disease (years) 8.76 (5.63)
Statistical analysis Gender, n (%)
Male 5 (15.2)
Descriptive statistics were used to describe a clinical Female 28 (84.8)
demographic and baseline data. Repeated-measures Fitzpatricks skin type
III 10 (30.3)
analysis of variance (ANOVA) and paired Students t-test
IV 23 (69.7)
were used to compare the average mean of total History of previous treatment
lesional surface area measured by PictzarTM software as Never 32 (97)
well as the length and width of striae at weeks 4, 8, Topical treatment 1 (3)
and 12 with the baseline data. Statistical data analysis
using IBM statistical package for the social sciences
(SPSS) version 19.0 (SPSS, Chicago, IL, USA) was
used. The P-value which is less than 0.05 is considered
as a statistical significance.

Results

Clinical demographics

This study conducted during February 1 to June 30,

2016. Thirty-three subjects were enrolled and com-
pleted all the study protocol. This study was regis-
tered to Thai Clinical Trial Registry (TCTR) (ID-TCTR
number 20160907003). The mean age  standard
deviation (SD) was 28  8.58 years. Twenty-eight
subjects (84.8%) were female and five (15.2%) were
male. Ten subjects (30.3%) had Fitzpatricks skin Figure 1 A comparison of total surface area at different visits
type III and 23 subjects (69.7%) had type IV. Total with the baseline.
duration of the disease was 8.76 years (Table 1).

width and the length of the striae had gradually

Primary outcomes: (Total surface area, and the length
and the width)
Total surface area (cm2)
The average mean (SD) total surface area by PictzarTM
software measurement at baseline was 6.41 
3.54 cm2, and had consecutively statistically signifi-
cant total surface area reduction from the baseline to
each follow-up visits (4.70  2.04, 3.55  1.80, and
2.55  1.52 cm2 at weeks 4, 8, and 12, consecu-
tively) (P < 0.001) (Fig. 1). The clinical improvement
picture assessed by PictzarTM is shown in Figure 2.
The Length and the Width (cm)
The average mean  SD of the width and the length
of the striae by caliper was 1.18  0.39 cm and
19.86  5.63 cm, respectively, at baseline visit. The
decreased from the baseline measurement to that of
each follow-up visits with statistical significance
(P < 0.001). (Table 2)
Secondary outcomes
Total surface area percent reduction, comparison between
different body sites
At 4-week visit, the thigh area had slightly lower aver-
age mean percent reduction in total surface area than
the abdomen and buttock areas (P = 0.001). But at
the study endpoint (12-week visit), there was no statis-
tically significant difference for percent reduction in
total surface area among the three different body sites
(ANOVA test, P = 0.404 and 0.253 at 8-week and 12-
week visit, respectively) (Fig. 3).

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Nanofractional RF for the treatment of striae alba . N Pongsrihadulchai et al.

Figure 2 To demonstrate significant total surface area reduction of striae alba by PictzarTM software at 4 weeks after three sessions of
the treatment.

Table 2 To show the baseline data and the change in total sur- (score 23). In terms of pain during the treatment, the
face area, the width and the length of the striae at different time mean pain score was 2.33  2.15 when defined score
points 0 as no pain and 10 as intolerable pain. The side effect
was postinflammatory hyperpigmentation (PIH) which
Clinical outcomes Mean SD P-value*
was observed in six patients (18.1%). However, they
Total Surface area (cm2) could be improved after treatment of topical 4% hydro-
Baseline 6.41 3.54 quinone.
Week 4 4.7 2.04 <0.001
Week 8 3.55 1.8 <0.001
Histological examination
Week 12 2.55 1.52 <0.001
Width (cm) Histopathological evaluation showed that at 12-week
Baseline 1.18 0.39 period, the number of collagen and elastin bundles sig-
Week 4 0.82 0.3 <0.001 nificantly increased when compared with the baseline
Week 8 0.66 0.23 <0.001
Week 12 0.59 0.25 <0.001
(P = 0.005 and 0.012, respectively). Moreover, the
Length (cm) collagen bundles became thicker and more densely
Baseline 19.86 5.63 accumulate at upper dermis than the baseline. At 12-
Week 4 16.85 4.64 <0.001 week visit, the epidermal thickness was also increased,
Week 8 14.12 3.92 <0.001
Week 12 11.4 4.71 <0.001
but did not show statistical significant difference with
the baseline (P = 0.793) (Fig. 5).
*Repeated-measures ANOVA or analysis of variance. There were five subjects (15.1%) that developed skin
P-value < 0.05, determined as significant value. hyperpigmentation which was resolved after the treat-
ment with 4% hydroquinone cream.
Figure 4a,c,e shows the striae at thigh, abdomen,
and buttock areas at baseline and Figure 4b,d,f repre-
Discussion
sents the clinical improvement observed at 4 weeks
after three sessions of the treatment at thigh, abdomen, The efficacy of fractional lasers for the treatment of SA
and buttock areas, respectively. has been demonstrated.79,21 Regarding fractional RF,
The patients satisfaction score increased throughout there were few studies that showed the benefit of
the study. The patients satisfaction at scores 4 and 5 microneedle RF in the treatment of SA and most physi-
(satisfied and very satisfied) for changes in texture, size, cians improvement score reported was at 3050%
and overall improvement at the last follow-up visit is improvement in the lesions.22
96.97%, 93.94 and 96.97%, respectively. The physi- Recently, the nanofractional RF, new innovative
cians satisfaction showed concordant results that technology, has been demonstrated in the treatment of
about 69.7% of all subjects had >50% improvement various facial skin conditions, including rhytides,

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 Nanofractional RF for the treatment of striae alba . N Pongsrihadulchai et al.

Figure 3 To demonstrate mean percent reduction in total surface area at thigh, abdomen, and buttock areas at baseline and at different
time points.

(a) (b)

(c) (d)

(e) (f)

Figure 4 To demonstrate clinical improvement in striae alba between different body sites with similar results.

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Nanofractional RF for the treatment of striae alba . N Pongsrihadulchai et al.

Figure 5 Histological examination to examine dermal collagen and elastin that stained by Masson trichrome (upper) and Verhoeff Van
Gieson (lower). The figures showed an increase in number and thickening of collagen bundles and increase in number of elastin content
at 4 weeks after the last treatment.

hyperpigmentation, skin laxity, and texture irregular-
ity.18,19 A retrospective study by Ray M et al. observed
that the nanofractional RF could improve facial striae
subjectively and could decrease mean skin roughness
by 6.7% after one session of the treatment.18 This cur-
rent study provided supportive evidence to the efficacy
of this device. It was discovered that the nanofractional
RF could improve various parameters of the SA not
only by subjective measurements but also by objective
assessments including the lesional surface area (by
PictzarTM software), width and length, and patients
and physicians satisfaction scores. In addition, the
histopathological study also demonstrated the incre-
ment in dermal collagen and elastin. To the best of our
knowledge, this study is the first prospective clinical
trial to evaluate efficacy and safety of the nanofrac-
tional RF in the treatment of SA in the body area.
Concerning the side effect, it was discovered that
PIH observed in the fractional lasers for the treatment
of SA on the body was 81.8% (fractional CO2 laser)
and 36.4% (fractional Erbium glass laser)9 which were
considered as quite high prevalence. Comparing to the
authors study, it was demonstrated that PIH observed
in the use of the nanofractional RF was 18.1% which
is lower than that of the fractional lasers. Comparing
the use of nonablative fractional microneedle RF by a
study of Ryu et al.,22 PIH observed was 20%; this
closely resembles the PIH in our study. Therefore, the
nanofractional RF is considered safe for the treatment
of SA even though it is an ablative fractional RF, and
the PIH observed is quite low.
From histopathological study, it was demonstrated
that the nanofractional RF could significantly induce
dermal collagen and elastin production at 4 weeks
after the last treatment (P = 0.005 and 0.012, respec-
tively). Although it failed to demonstrate significant
epidermal thickness increment (P = 0.793), the
authors suggested that 4 weeks after the last treatment
might be too short to detect the statistically significant
difference in the epidermal thickness.
The strength of our study is that there were various
objective measuring methods such as PictzarTM software,
width and length, and histopathological assessment as
well. Moreover, there were comparison between body
sites responses to the treatment and this was the first
prospective clinical trial with blinded assessors.
The limitation was that the measurement in this
study was only two dimensional; therefore, it might
not clearly represent improvement in SA as the lesion
has three dimensions; width, length, and depth, and
also this study lacks the roughness or elasticity mea-
surement.
Thus, our suggestion for further study is a longer
follow-up period after the last treatment to detect

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 Nanofractional RF for the treatment of striae alba
long-term effects. Three-dimensional measurement
(such as the use of AnteraTM camera), roughness (such
as the use of VisioscanTM; Courage+Khazaka Electronic
GmbH, K oln, Germany), and elasticity (such as the use
of and CutometerTM; Courage+Khazaka Electronic
GmbH) measurement should also be included. Addi-
tionally, the optimum parameter for striae alba should
be studied for the best results at the lowest adverse
effects. Lastly, as this study already documented the
efficacy of this device in the treatment of striae alba, in
the future, the next study can compare the efficacy of
this device with other devices.
In conclusion, the nanofractional RF is highly effec-
tive and safe for the treatment of striae alba. Therefore,
it could be recommended as a new treatment of striae
alba.
Acknowledgments
We would like to thank Faculty of Medicine, Sri-
nakharinwirot University, for providing full grant for
this study.
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