The Correlation between Serum Cortisol Levels with Stretch Marks in Gymnastic Male

Abstract

BACKGROUND: Stretch marks are skin scar tissue that appears in the form of purplish linear atrophy, erythematous or hypopigmented which is often caused by excessive stretching of the skin. Increased cortisol levels can cause an increase in collagen degradation which results in disruption of the extracellular matrix in the dermis, resulting in stretch marks. Physical stress can trigger activation of the hypothalamic-pituitary-adrenal axis, which will induce activation of stress hormones, including cortisol in the adrenal cortex. AIM: The objective of the study is to determine the correlation between serum cortisol levels and stretch marks in male at a gymnastics training site. SUBJECTS AND METHODS: Observational analytic study with a cross-sectional approach to 50 stretch marks subjects. RESULTS: Serum cortisol levels of subjects with stretch marks averaged 9.72 g/dL with the lowest level of 4.45 g/dL and the highest level of 49.25 g/dL (p < 0.001). The highest age with stretch marks was 26–30 years 18 (36%) subjects and the lowest age was aged 36–40 years 5 (10%) subjects. The majority of stretch marks are located in the axillary region (30.9%), brachii (23.6%), and abdomen (18.4%). The average cortisol level in subjects with aerobic exercise was 6.52 g/dL, muscle training 11.18 g/dL, mixed aerobic and muscle training 7.5 g/dL. The highest average cortisol levels were at exercise duration of 31–60 min of 12.88 g/dL, 61–90 min of 6.63 g/dL, and 91–120 min of 6.2 g/dL. The highest frequency of exercise in a week was 3–4 times as many as 30 subjects (60%) with an average serum cortisol level of 11.1879 g/dL. CONCLUSION: There is a significant correlation between serum cortisol levels and stretch marks in male at gymnastics training.

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Scientic Foundation SPIROSKI, Skopje, Republic of Macedonia
Open Access Macedonian Journal of Medical Sciences. 2022 Jan 31; 10(B):150-153.
https://doi.org/10.3889/oamjms.2022.8109
eISSN: 1857-9655
Category: B - Clinical Sciences
Section: Dermatology
The Correlation between Serum Cortisol Levels with Stretch Marks
in Gymnastic Male
Rezky Darmawan Hatta1*, Imam Budi Putra2, Nelva Karmila Jusuf2
1Department of Dermatology and Venereology, Postgraduate Master of Clinical Medicine, Faculty of Medicine, Universitas
Sumatera Utara, Universitas Sumatera Utara Hospital, Medan, Indonesia; 2Department of Dermatology and Venereology,
Faculty of Medicine, Universitas Sumatera Utara, Universitas Sumatera Utara Hospital, Medan, Indonesia
Abstract
BACKGROUND: Stretch marks are skin scar tissue that appears in the form of purplish linear atrophy, erythematous
or hypopigmented which is often caused by excessive stretching of the skin. Increased cortisol levels can cause
an increase in collagen degradation which results in disruption of the extracellular matrix in the dermis, resulting
in stretch marks. Physical stress can trigger activation of the hypothalamic-pituitary-adrenal axis, which will induce
activation of stress hormones, including cortisol in the adrenal cortex.
AIM: The objective of the study is to determine the correlation between serum cortisol levels and stretch marks in
male at a gymnastics training site.
SUBJECTS AND METHODS: Observational analytic study with a cross-sectional approach to 50 stretch marks
subjects.
RESULTS: Serum cortisol levels of subjects with stretch marks averaged 9.72 g/dL with the lowest level of
4.45 g/dL and the highest level of 49.25 g/dL (p < 0.001). The highest age with stretch marks was 26–30 years
18 (36%) subjects and the lowest age was aged 36–40 years 5 (10%) subjects. The majority of stretch marks are
located in the axillary region (30.9%), brachii (23.6%), and abdomen (18.4%). The average cortisol level in subjects
with aerobic exercise was 6.52 g/dL, muscle training 11.18 g/dL, mixed aerobic and muscle training 7.5 g/dL. The
highest average cortisol levels were at exercise duration of 31–60 min of 12.88 g/dL, 61–90 min of 6.63 g/dL, and
91–120 min of 6.2 g/dL. The highest frequency of exercise in a week was 3–4 times as many as 30 subjects (60%)
with an average serum cortisol level of 11.1879 g/dL.
CONCLUSION: There is a signicant correlation between serum cortisol levels and stretch marks in male at
gymnastics training.
Edited by: Ksenija Bogoeva-Kostovska
Citation: Hatta RD, Putra IB, Jusuf NK. The Correlation
between Serum Cortisol Levels with Stretch Marks in
Gymnastic Male. Open Access Maced J Med Sci. 2022
Jan 31; 10(B):150-153.
https://doi.org/10.3889/oamjms.2022.8109
Keywords: Stretch marks; Cortisol serum; Male;
Gymnastic
*Correspondence: Rezky Darmawan Hatta, Department
of Dermatology and Venereology, Postgraduate Master
of Clinical Medicine, Faculty of Medicine, Universitas
Sumatera Utara, Universitas Sumatera Utara Hospital,
Medan, Indonesia. E-mail: rezkydeha@icloud.com
Received: 28-Nov-2021
Revised: 21-Jan-2022
Accepted: 24-Jan-2022
Copyright: © 2022 Rezky Darmawan Hatta,
Imam Budi Putra, Nelva Karmila Jusuf
Funding: This research did not receive any nancial
support
Competing Interest: The authors have declared that no
competing interest exists
Open Access: This is an open-access article distributed
under the terms of the Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0)
Introduction
Striae distensea or stretch marks are a type
of skin scar tissue that appears in the form of purplish
linear atrophy, erythematous or hypopigmented
which is often caused by excessive stretching of the
skin [1], [2]. Stretch marks are clinically in the form of
atrophic scars that are initially reddish or purplish in
color and overtime it tends to fade gradually and turn
white [3]. Stretch marks are not a dangerous disease,
but they can cause cosmetic and psychological
problems for su󰀨erers [4].
The hypothesis of the pathogenesis of stretch
marks is divided based on the underlying etiological
theory, namely, genetic factors, pathological factors,
hormonal factors, and mechanical factors [5]. Increased
cortisol levels can cause an increase in collagen
degradation which results in disruption of the
extracellular matrix in the dermis, this can result in
stretch marks [6]. The mechanism for the formation
of stretch marks caused by the action of steroid
hormones and glucocorticoid hormones appears to
be an imbalance of the dermal connective tissue
and/or dermal matrix rather than mechanical stress [5].
High levels of steroid hormones and glucocorticoid
hormones have a catabolic e󰀨ect on broblast activity
and reduce collagen deposition. in the dermal matrix
substance [7]. The pathogenesis of stretch marks,
according to Shuster, is caused by cross-linking of
immature collagen in the dermis, resulting in intradermal
rupture causing stretch marks. It has been found that in
stretch marks there is a deposition of collagen bundles
and the formation of scar tissue which has implications
for the formation of stretch marks [7].
Physical stress can trigger the activation
of a number of physiological responses, including
the endocrine, nervous, and immune systems. The
physiological response to stress involves activation
of the hypothalamic-pituitary-adrenal (HPA) axis,
and the medullary sympathetic-adrenal axis, both
of which interact with immune function. Activation of
the HPA axis will induce the activation of key stress
hormones, including corticotropin-releasing hormone

Hatta et al. Correlation between Serum Cortisol Levels with Stretch Marks in Gymnastic Male
Open Access Maced J Med Sci. 2022 Jan 31; 10(B):150-153. 151
in the hypothalamus, adrenocorticotropic hormone in
the anterior pituitary, and cortisol in the adrenal cortex,
which in turn will disrupt the balance of cellular immunity
mediated by T-helper (Th) 1 and humoral immunity is
mediated by Th2 [8], [9]. This study is conducted to nd
the correlation serum cortisol levels and stretchmark in
gymnastic male.
Methods
This study was an analytic observational study
with a cross-sectional design consisting of 50 stretch
marks subjects and 50 controls with age ≥18 years old
that normal weight and doing exercise in gymnastics.
Each subject had signed the informed consent. The
exclusion criteria were subjects with cushing’s syndrome
or Marfan’s syndrome, have a history of obesity, using
oral or topical steroids and topical tretinoin for more
than 6 months before the rst appearance of stretch
marks, taking drugs that a󰀨ect cortisol levels such as
antidepressants, antipsychotics, and anti-anxiety drugs
in the past 30 days.
Ethical permission is given by the Health
Research Ethics Committee, Faculty of Medicine,
Sumatera Utara University, and Universitas Sumatera
Utara Hospital Medan. History taking and clinical
examination were conducted, and measurement
of serum cortisol levels. The results were analyzed
in descriptive analysis and MannWhitney test to
determine the correlation between serum cortisol levels
with stretch marks in gymnastic male, with p < 0.05 was
considered signicant.
Results
In this study, the majority of subjects were aged
26–30 years with 18 (36%) subjects, and the majority
control group were aged of 18–25 years as many as
19 (38%) subjects. The demographic characteristics
of the subjects were shown in Table 1. From 50
subjects with stretch marks, we found 152 stretch
marks distributed in several predilections, and most
were found in the axilla (30.9%) and a brachii (23,6%)
(Table 2).
In the stretch marks, group cortisol levels were
9.72 g/dL with the lowest level of 4.45 g/dL and the
Table 1: Distribution of subjects and controls based on age
Age (year) Subject % Control %
18–25 13 26 19 38
26–30 18 36 14 28
31–35 14 28 14 28
36–40 5 5 3 6
Total 50 100 50 100
Table 2: Distribution of subjects by location of stretch marks
Location n%
Axsilla 47 30,9
Brachii 36 23,6
Abdomen 28 18,4
Lumbosacral 16 10,5
Gluteus 15 9,8
Femur 8 5,2
Poplitea 2 1,3
Total 152 100
Table 5: Distribution of subjects based on the duration of
exercise
Duration of exercise (min) n% µg/dL
1–30 2 46,1593
31–60 23 48 12,8788
61–90 17 34 6,6322
91–120 48 6,2064
>120 46 6,3625
Total 50 100
highest level of 49.25 g/dL. Meanwhile, in the group of
subjects who did not have stretch marks, the cortisol
value was much lower with an average of 3.83 g/dL with
the lowest level of 1.84 g/dL and the highest level of
5.39 g/dL as shown in Table 3.
Table 3: Relationship of serum cortisol levels with stretch
marks
Cortisol, µg/dL Stretch marks ( + ) n = 50 Stretch marks ( - ) n = 50 p
Mean 9.72 (9.44) 3.83 (0.89) <0.001*
Median
(Min–Max)
6.37 (4.45–49.25) 3.85 (1.84–5.39)
In Table 4 shows the results of the type of
exercise and serum cortisol levels, the average cortisol
level in the 11 subjects with aerobic exercise was 6.52 g/
dL, the average cortisol level in the 11 subjects with
exercise muscle training was 11.18 g/dL, the average
cortisol level in the 11 subjects with aerobic exercise
and muscle training was 7.5 g/dL.
Table 4: Distribution of exercise types with serum cortisol
levels
Exercise type nµg/dL
Aerobic 11
Mean (SD) 6.52 (1.48)
Median (Min–Max) 6.44 (4.75–8.41)
Muscle training 33
Mean (SD) 11.18 (11.26)
Median (Min–Max) 6.51 (4.45–49.25)
Aerobic dan muscle training 6
Mean (SD) 7.5 (3.87)
Median (Min–Max) 5.81 (5.02–14.96)
In Table 5 show that the 50 most subjects
did exercise with a duration of 31–60 min, as much
as 23 people (48%) with a serum cortisol level of
12.8788 g/dL, followed by a duration of 61–90 min, as
much as 17 people (34%) with a serum cortisol level
of 6.6322 g/dL. Distribution of subjects based on the
frequency of exercise in a week and serum cortisol
levels in 50 subjects who have stretch marks shown
in Table 6, it can be seen that 50 subjects did exercise
with a frequency of 1–2 times, 7 people (14%) with
a serum cortisol level of 8.1737 g/dL, followed by a
frequency of 3–4 times, 30 people (60%) with the serum
cortisol level was 11.1879 g/dL and with a frequency of
5–7 times, 13 people (26%) with a serum cortisol level
of 7.1460 g/dL.

B - Clinical Sciences Dermatology
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Table 6: Distribution of subjects based on the frequency of
exercise in a week
Frequency of exercise n% µg/dL
1–2 times 7 14 8,1737
3–4 times 30 60 11,1879
5–7 times 13 26 7,1460
Total 50 100
We then analyzed them with the
MannWhitney test and found that there was a
significant correlation between stretch marks and
cortisol serum levels (p < 0.001).
Discussion
Stretch marks are a very common condition in
most age groups in the form of linear atrophic scars
that form in areas of skin damage and are produced by
stretching 20. In the early stages, stretch marks appear
as pink or purple lesions without any compression, but
gradually stretch marks become paler, compressed, and
wrinkled [10], [11]. Stretch marks occur in pregnancy
(43% to 88%), puberty (6% to 86%), and obesity
(43%).5 70% of adolescent girls, and 40% of boys (who
are active in sports) have stretch marks [12].
Table 1 showed that the majority of subjects
were aged 26–30 years with 18 (36%) subjects and the
majority control group were aged 18–25 years as many
as 19 (38%) subjects. This study is consistent with
the study by Dharmesti et al. in Denpasar, Indonesia
conducted on 28 males, the mean age was 20.6 years.
73 Trojan et al. in Lodz, Poland conducted a study on
80 people with stretch marks and found the average
age was 23.9 ± 2.05 years [13].
We found 152 stretch marks distributed in
several predilections, and most were found in the axilla
(30.9%) and a brachii (23.6%). In line with the research
conducted by Dharmesti et al. in Denpasar, Indonesia
which was conducted on 28 males, it was found that
striae distensae developed the most in the forearm
area (29.6%), followed by the abdominal area (15.5%),
then gluteus and lumbosacral areas with the same
percentage (9.9%). 73 In this study, the most common
locations for stretch marks in the axillary and brachial
regions were due to the dominant movement factor in
the gymnastics using upper extremity movements [13].
Based on Table 3, In the stretch marks group,
cortisol levels were 9.72 g/dL, meanwhile, in the
group of subjects who did not have stretch marks,
the cortisol value was much lower with an average of
3.83 g/dL. This study is consistent with Simkim and
Arce studied 24-h urinary excretion of 17-ketosteroids
and 17-ketogenic steroids in obese patients. Although
the mean excretion of all obese patients (15.8 mg) was
signicantly higher, compared with non-obese patients,
excretion was higher in obese patients who had skin
striae (20.4 mg). Approximately 78% of obese patients
with striae showed an increase in 17-ketosteroids, but
this result was not statistically signicant [14].
In this study, from 50 subjects with stretch marks,
we found the type of exercise and serum cortisol levels,
the average cortisol level in the 11 subjects with aerobic
exercise was 6.52 g/dL, the average cortisol level in the
11 subjects with exercise muscle training was 11.18 g/dL,
the average cortisol level in the 11 subjects with aerobic
exercise and muscle training was 7.5 g/dL. Cortisol levels
that increase during exercise are caused by changes in
homeostasis with an increase in energy requirements that
are higher than the control group. This is in accordance
with the study of Howlett et al., which showed a higher
increase in cortisol in moderate exercise. The increase
occurs due to an increase in the need for blood glucose
through the gluconeogenesis pathway [15].
In Table 5 show that the 50 most subjects
did exercise with the highest serum cortisol level of
12.8788 g/dL in the duration of 31–60 min, as much as 23
people (48%). In Table 6, it can be seen that 50 subjects
did exercise with a frequency of 1–2 times, 7 people (14%)
with a serum cortisol level of 8.1737 g/dL, followed by a
frequency of 3–4 times, 30 people (60%) with the serum
cortisol level was 11.1879 g/dL and with a frequency of
5–7 times, 13 people (26%) with a serum cortisol level of
7.1460 g/dL. Seller et al. conducted a biological study to
see a signicant glucocorticoid response during exercise
in experimental animals and found that in short-term
exercise blood cortisol levels increased if the intensity of
exercise was above a certain threshold [16].
Conclusion
There is a correlation between serum cortisol
levels with stretch marks in gymnastic male.
Acknowledgments
We want to express gratitude to the Head of
the Cosmetic Division Department of Dermatology and
Venereology of Faculty of Medicine Universitas Sumatera
Utara and Universitas Sumatera Utara Hospital.
Author Contribution
All authors have contributed to this research
process, including preparation, data gathering, analysis,
drafting, and approval to publish this manuscript.

Hatta et al. Correlation between Serum Cortisol Levels with Stretch Marks in Gymnastic Male
Open Access Maced J Med Sci. 2022 Jan 31; 10(B):150-153. 153
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