Edematous fibrosclerotic panniculopathy, or local lipodystrophy, better known as cellulite, may be best characterized as a skin surface alteration, nodularity, or dimpling that occurs in most women, typically in the buttocks and upper thighs, as well as the abdomen (Int. J. Cosmet. Sci. 2006;28:191-206). These lesions are typically depressed, compared with adjacent unaffected skin. Cellulite also is known as adiposis edematosa, dermopanniculosis deformans, status protrusus cutis, and gynoid lipodystrophy.
Risk factors for cellulite include being female, overweight or obese, and elderly; having excess hormones or poor lymphatic drainage; and getting little exercise. Although cellulite often occurs in healthy, nonobese patients, obesity is known to exacerbate it (Dermatol. Surg. 1997;23:1177-81; J. Cosmet. Dermatol. 2005;4:221-2; Am. J. Dermatopathol. 2000;22:34-7).
Estimates of the frequency of cellulite in women range from 80% to 98% of postadolescent females across cultures (J. Dtsch. Dermatol. Ges. 2006;4:861-70; J. Cosmet. Laser Ther. 2004;6:181-5).
Etiology
The etiology of cellulite remains unclear, although several theories have been advanced (J. Cosmet. Laser Ther. 2005;7:7-10; Int. J. Cosmet. Sci. 2006;28:191-206; J. Cosmet. Laser Ther. 2004;6:181-5). Factors that have been cited as important in the pathophysiologic process include sex-specific morphologic differences, vascular changes, inflammation, and deterioration in connective tissue septa (J. Cosmet. Laser Ther. 2004;6:181-5; J. Dtsch. Dermatol. Ges. 2006;4:861-70).
One train of thought suggests that cellulite is derived from a disorder of endocrine-metabolic microcirculatory origin, in which changes in subcutaneous adipose tissue and the interstitial matrix manifest in unsightly bumps (Int. J. Cosmet. Sci. 2006;28:191-206).
The anatomy of this condition is an important factor. The morphologic differences in the fat lobes of men and women may account for the much greater frequency of this presentation in females. The degradation of collagen in the reticular dermis is thought to contribute to the development of cellulite by promoting weakness and compression of microcirculation in the dermis, as well as herniation of subcutaneous fat into the dermal layer. The characteristic signs of cellulite are then believed to result from the congestion of fluid and proteins in the dermis, forming fibrotic bands between the subcutaneous tissue and the dermis. Physiologic changes in the dermis, rather than in the subcutaneous fat layer, are thought to be primary.
Modes of Treatment
Although no treatment approaches have been deemed entirely successful, given their typically mild and temporary effects, cellulite therapies have included the use of noninvasive devices such as massage machines, radiofrequency systems, and laser and other light instruments; invasive surgery such as liposuction, mesotherapy, and subcision; carboxy therapy; topical therapy; and even oral modalities (J. Drugs Dermatol. 2008;7:341-5; J. Drugs Dermatol. 2007;6:83-4).
Massage appears to be the most effective modality for low-grade cellulite, as it is conducive to enhancing blood and lymphatic circulation and draining waste products. The effects are temporary, however, as they are with even the most effective topical products, which contain caffeine and theophylline and dehydrate the fat cells, temporarily shrinking them. For the highest-grade cellulite lesions, minimally invasive procedures such as subcision can render improvement (Int. J. Dermatol. 2000;39:539-44).
Topical Treatments
Despite the slew of products touted for treating cellulite, few have been tested in clinical trials.
In 1999, a 12-week, randomized, controlled trial evaluated the effectiveness of two different cellulite creams, aminophylline and a placebo, as well as the Endermologie ES1 massage machine (LPG Systems S.A.). Sixty-nine women began the study, and 52 women completed it.
The treatments studied were twice-daily application of aminophylline cream and twice-weekly use of the Endermologie. Patients served as their own controls. In group 1 (double blind), aminophylline was applied to one thigh/buttock and a placebo cream to the other. In group 2 (single blind), the Endermologie was applied to one thigh/buttock. In group 3, the Endermologie was applied to both sides, and the same cream regimen as in group 1 was used.
Clinical examination and photographic assessment before and after the trial revealed no statistically significant measurement differences between legs in any of the groups. The appearance of cellulite was judged in subjective assessments to have improved in only 3 of 35 legs treated with aminophylline and in 10 of 35 legs treated with the Endermologie machine. The investigators concluded that neither of the tested modalities is effective for cellulite treatment (Plast. Reconstr. Surg. 1999;104:1110-4).
In 2000, investigators reported the effects of topical retinol for treating cellulite in a left-right randomized, 6-month trial comparing the retinol with a placebo. The subjects included 15 women aged 26-44 years who had requested liposuction to ameliorate mild to moderate cellulite.
Following the treatment period, the researchers recorded an 11% increase in skin elasticity and a 16% decrease in viscosity in the retinol-treated area. It is important to remember that there is no accepted device that everyone agrees accurately measures skin elasticity, so these results must be interpreted with caution (Am. J. Clin. Dermatol. 2000; 1:369-74).