Discussion
Striae Distensae, are common skin lesions characterized by linear
atrophic plaques directed perpendicularly to the
skin.2,4 They represent either, benign physiological
changes as during pregnancy and adolescence, or a pathological sign of
certain diseases.4 Rarely, bullae can develop within
the striae.5,6,7 They exhibit lower hydration levels
in both the epidermis and dermis, along with reduced dermal echo density
and elasticity compared to normal skin.10 A rare
variation of stria distensae, Bullous Stria Distensae, is characterized
by the development of tense bullae within the stria. Almashat et al.
suggested that patients with nephrotic syndrome and chronic steroid use
may trigger bullous stria development, particularly in cases of
anasarca.2,7 The pathogenesis of BSD remains
uncertain, however, it has been hypothesized that mechanical stress on
the dermis leads to the rupture of the dermal vasculature and subsequent
bullae formation. Seshadri et al. additionally proposed that the weak
tensile strength of the stria may contribute to the build-up of fluid
within them. Besides, as the size of the stria increases, the likelihood
of fluid accumulation also increases.3 Masoud et al.
reported that patients on oral steroids, developing generalized body
edema, tend to accumulate fluid, particularly in the striae. They
further put forward a hypothesis that the phenomenon might result from
the combined effect of both anasarca and steroid medication.
Glucocorticoids were thought to enhance the collagen breakdown, reducing
tensile strength allowing fluid to accumulate preferentially from
anasarca within the stria spaces, forming fluid-filled
sacs.5
In our case, a 17-year-old female with nephrotic syndrome presented with
an emergence of bullous lesions on her abdominal striae. The distinctive
histopathologic characteristics of edematous dermis with a slightly thin
and horizontally oriented dermal collagen confirmed the diagnosis of
BSD. With regard to fluid aspiration culture and sensitivity report, the
bullae were found to be sterile, which is consistent with a previous
report by Seshadri et al.3 To the best of our
knowledge, this is the fourth case reported the occurrence of bullous
skin disease in a patient with nephrotic syndrome documented in the
literature. The rapid weight gain and the presence of ascites in our
patient may have resulted in increased mechanical stress on the dermis,
which contributed to the development of BSD. The coexistence of
lipodystrophy and hypoproteinemia in nephrotic syndrome may have further
weakened dermal collagen, potentially increasing the patient’s
susceptibility to BSD development.2,4 In our case and
other reported cases, patients had hypoalbuminemia due to different
pathologies and striae Distensae. Three of the reported cases were
associated with receiving high or fluctuating dose of systemic steroid
for varying duration.2,3,7 This phenomenon can be
explained by the effect of decreased oncotic pressure on weakened or
atrophic layers of skin.6 In this clinical context,
differential diagnosis includes autoimmune bullous diseases, which can
be ruled out through direct immunofluorescence. However, managing the
underlying medical illness with diuresis can lead to spontaneous
resolution, as puncture and aspiration of fluids alone would result in
rapid fluid reaccumulation. Jogova et al. also highlighted that upon
treatment with diuresis, flattening of the fluid-filled stria were
notable.4 Certainly, BSD management is primarily
centred around addressing the underlying cause. In our case, the
administration of diuretics to manage her ascites played a role in
reducing the mechanical stress on the dermis, which resulted in a
gradual resolution of the bullae. The strength of our case report lies
in its rarity, as we are only the second case report highlighting the
potential advantage of employing diuresis as a management approach for
BSD. It is crucial to attain optimal management of nephrotic syndrome to
minimize the risk of BSD, considering the ongoing fluid shifts and the
chronic use of corticosteroid. Future research is needed to enhance the
understanding of the underlying pathogenesis of BSD. Additionally,
further clinical trials are imperative to thoroughly assess the efficacy
of diuresis as a viable management approach for BSD in order to
establish the optimal management approaches for treating the condition.
By shedding light on this barely explored area, the novelty of our
findings contributes to enhancing the understanding of the potential
therapeutic options for addressing bullous stria distensa.