Cellulite describes a condition that occurs in men and women where the skin of the lower limbs, abdomen, and pelvic region becomes dimpled after puberty.^[1] The term was first used in the 1920s and began appearing in English language publications in the late 1960s, the earliest reference in Vogue magazine, "Like a swift migrating fish the word cellulite has suddenly crossed the Atlantic."^[2]

Descriptive names for cellulite include orange peel syndrome, cottage cheese skin, the mattress phenomenon, and hail damage. Synonyms include: adiposis edematosa, dermopanniculosis deformans, status protrusus cutis, and gynoid lipodystrophy. Cellulite is unrelated to cellulitis, which is infection of the skin and its underlying connective tissue.

Occurrence

Practically all post-pubescent females display some degree of cellulite. There appears to be a hormonal component to its presentation. It is rarely seen in males.^[1] It is seen more commonly in males with androgen-deficient states such as Klinefelter's syndrome, hypogonadism, post-castration states and in those patients receiving estrogen therapy for prostate cancer. The cellulite becomes more severe as the androgen deficiency worsens in these males.

Cellulite is not related to being overweight; average and underweight people also get cellulite.^[1]

Causes

The causes are poorly understood, and several changes in metabolism and physiology may cause cellulite or contribute to cellulite. Among these are a disorder of water metabolism, abnormal hyperpolymerization of the connective tissue, and chronic venous insufficiency.^[1]

Hormonal factors

Hormones play a dominant role in the formation of cellulite. Estrogen is the most important hormone. It seems to initiate, and aggravate cellulite. Other hormones including insulin, the catecholamines adrenaline and noradrenaline, thyroid hormones, and prolactin have all been shown to participate in the development of cellulite.^[1]

Predisposing factors

Several genetic factors have been shown to be necessary for cellulite to develop. Gender, race, biotype^[3], a hormone receptor allele that determines the receptor number and sensitivity, distribution of subcutaneous fat, and predisposition to circulatory insufficiency have all been shown to contribute to cellulite.^[1]

Diet

Diet has been shown to affect the development and amount of cellulite. Excessive amounts of fat, carbohydrates, salt, alcohol or too little fiber can all contribute to an increased cellulite.^[1]

Lifestyle

Smoking, lack of exercise, tight clothes, high heeled shoes, and sitting or standing in a single position of long periods have all been correlated with an increase in cellulite. A high stress lifestyle will cause an increase in the catecholamine hormones.^[1]

Classification

Grade 1

No clinical symptoms, but histopathology detects underlying anatomical changes.^[1]

Grade 2

The skin shows pallor, lower temperature, and decreased elasticity after compression or muscular contraction. There is no visible "orange peel" roughness to the skin. Additional anatomical changes are detected by histopathology.^[1]

Grade 3

Visible "orange peel" roughness to the skin is visible at rest. This is the "canonical" grade of cellulite. Thin granulations in the deep levels of the skin can be detected by palpitation. All Grade 2 signs are present, with further anatomical changes are detectable by histopathology.^[1]

Grade 4

All Grade 3 symptoms are present, with more visible, palpable, and painful lumps present which adhere to deep structures in the skin. The skin has a noticeable dimpled, wavy appearance. Additional histopathologic changes are detected.^[1]

Therapy

Numerous therapies have been tried. There are no published reports in the scientific literature showing that any of these therapies work.

The most beneficial therapy is to control lifestyle factors. Controlling stress and anxiety are of considerable benefit.

Physical and mechanical methods

Iontophoresis, ultrasound, thremotherapy, pressotherapy (pneumatic massaging in the direction of the circulation), lymphatic drainage (massage technique to stimulate lymphatic flow), electrolipophoresis (application of a low frequency electric current) have all been tried.^[1]

Pharmacological agents

Any number of drugs that act on fatty tissue have been tried as therapeutic agents. Certain drugs act on the fatty tissue and connective tissue and on the microcirculation. They can be used topically, systemically, or transdermally.

These include the methyxanthines (theobromine, theophylline, aminophylline, caffeine), which act through phosphodiesterase inhibition, and pentoxifylline which improves micro-circulation; the adrenergic beta-agonists isoproterenol and adrenaline; the adrenergic alpha-agonists yohimbine, piperoxan, phentolamine and dihydroergotamine; the methyIxanthine enhancers Coenzyme A and the amino acid l-carnitine; the drugs with connective tissue activity sillicium and Asiatic centella; and the microcirculation active drugs Indian chestnut, ginkgo biloba, and rutin.

These drugs are administered orally, as topically applied ointments, and by trans-dermal injection.

None of them has been reported in the scientific literature as having a significant effect on cellulite.

Cosmetic concern

While harmless, the dimpled appearance is a cause of concern for some people. The cosmetics industry claims to offer many of what it calls remedies. There are no supplements that have been approved as effective for reducing cellulite.

Syneron, the first cosmetic laser manufacturer to receive FDA clearance for treating cellulite, combine mechanical, light, heat, and radio frequency energy, also known as ELOS, to the skin and claim success after a few applications of their product.

Radio frequency in the cosmetic industry is used to heat the skin in a non-invasive (medical) cosmetic procedure to heat the fat tissue underneath the skin. That procedure regenerates the collagen in the area and makes the skin look younger and more vital.

Other cosmetic procedures such as Mesotherapy and Endermologie have produced inconclusive results. While each has been FDA approved to temporarily reduce the appearance of cellulite, effectiveness varies by procedure. All methods require continual follow-up to maintain reduced levels of cellulite. "No statistical difference existed" in morphologic assessment of the body after 12 weeks of randomised control trial with Endermologie (Collis N et al. 1999 Sep;104(4):1110-4 Plast Reconstr Surg)

Liposuction, which extracts fat from under the skin, is not effective for cellulite reduction and may exacerbate the cosmetic problem. Dieting does not get rid of the dimpled appearance, but a balanced diet and exercise may help to reduce the fat content within the distorted cells, reducing their contribution to the dimpling.

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