Cellulite

Author: Sharon Wai Cheng Fong, Dermatology Selective Medical Student, Auckland University Faculty of Medicine and Health Sciences, New Zealand, 2010.

What is cellulite?

Cellulite is the skin dimpling and lumpiness seen on the skin surface of the thighs, buttocks and abdomen of nearly all women. It is due to fatty protrusions into the dermis layer of skin. It causes no physical harm but may cause embarrassment.

Who is at risk of cellulite?

The actual cause of cellulite is poorly understood. However, factors that affect the incidence of cellulite include:

Genetic predisposition
Hormones — insulin increases fat content
Sex — cellulite is more common in females compared to males
Ethnicity — cellulite is more likely to affect Caucasian than Asian women
Diet — excessive carbohydrate intake may enhance cellulite
Obesity — cellulite is often more noticeable in those with high body mass index (BMI)
Weight change — weight gain can accentuate the appearance of cellulite, but weight loss can improve or worsen it
Lifestyle — prolonged periods of sitting/ standing may worsen cellulite
Pregnancy — increase in insulin, prolactin and fluid volume may influence cellulite.

How is cellulite graded?

Cellulite has been divided into three main grades based on the clinical severity.

Grade I	Smooth skin without any dimpling upon standing up and lying down Mattress-like configuration upon pinching the skin
Grade II	Mattress-like appearance upon standing but disappears in supine position
Grade III	Skin dimpling upon standing and supine position Skin dimpling is exacerbated by pinching the skin

What is the treatment for cellulite?

Weight loss should be encouraged in those who are overweight, but may not improve the appearance of the affected skin.

The treatment options currently available for treating cellulite are listed in the table below.

Endermologie®	A device used to mechanically massage fat in the affected area Treatments repeated twice weekly appear to reduce thigh size Treatment is costly with little evidence of long-term efficacy
Liposuction	Liposuction is effective for removing large areas of deeply placed subcutaneous fat Fatty tissue of cellulite is close to the skin surface where liposuction may be risky Lipoplasty is not recommended for cellulite because of poor cosmetic outcomes
Subcision	Surgical procedure using a needle to to cut fibrous bands between fat lobules May temporarily improve the skin dimpling, but long-term efficacy is uncertain
Mesotherapy	Various substances eg, phosphotidylcholine or deoxycholate, may be injected into subcutaneous tissue to dissolve fat Precise treatment protocols are lacking Outcome is unpredictable, and dimpling may get worse May cause abscesses and scarring
Bipolar and unipolar radiofrequency devices, eg, VelaSmooth®, TriActive™, Accent XL, ThermaCool®	Various devices are under investigation Small studies have shown mixed but sometimes impressive results; long-term efficacy is unknown VelaSmooth® approved by US Food and Drug Administration (FDA); combines infrared light (700–2000 nm), bipolar radiofrequency, suction and mechanical massage Bipolar devices penetrate >3 mm for better control of localised fatty deposits Unipolar devices use high frequency electromagnetic radiation with greater depth and breadth of thermal damage but diffuse pattern results in less control
Ultrasound devices, eg, UltraShape®	Ultrasound can destroy fat cells Efficacy in cellulite is unknown
Laser-assisted lipolysis, eg, Smartlipo™	Certain lasers destroy targeted areas of fat and tighten the skin Laser assisted lipoplasty using Nd:YAG laser may be suitable for small areas of fat deposition Efficacy for cellulite may not be as good as when liposuction is used for large areas of fat
Topical medications	Retinoic acid (retinol) used over a period of >6 months has been shown to improve cellulite, probably by increasing dermal collagen thickness and contour of elastic fibres Topical aminophylline has not been shown to objectively improve cellulite; however, some patients have reported improvement Several herbal creams are marketed for cellulite, containing ingredients such as caffeine and botanicals of unknown efficacy; some components may cause contact allergic dermatitis Carboxy therapy is the injection of carbon dioxide into fatty tissue, and is intended to dissolve fat (lipolysis) Peroxisome proliferator-activated receptor agonists are newly discovered nuclear transcription factors activated by petroselinic acid and conjugated linoleic acid; they are being investigated as they appear to improve epidermal differentiation, reduce inflammation, increase extracellular matrix components and elicit skin tightening; conjugated linoleic acid can prevent fat accumulation in fat cells
Cryolysis eg, Cryolipolysis™	Cooling the skin surface is being evaluated for cellulite and body contouring, as freezing destroys fat cells