While hanging out in the PEERtrainer lounge this morning, I noticed folks were chatting about cellulite. Of course, most women know about cellulite, that annoying dimpling of the skin on our thighs and buttocks. Many of us have spent some effort and, perhaps, more than a little money trying to get rid of it, usually without much success. But what is cellulite anyway? And does anything really work to make it go away?
Mathew Avram, a physician at the David Geffen School of Medicine in Los Angeles, has published a scholarly review of cellulite and its treatment in the Journal of Cosmetic Laser Therapy (2004,6:181-185). Here are the key points:
- Cellulite is very common. Between 85% to 98% of women past the age of puberty have cellulite; it rarely occurs in men.
- It appears to have a relationship to our hormone status. It occurs after puberty in women. Men who are deficient in male hormones or who receive female hormones, such as estrogen therapy for prostate cancer, may develop cellulite.
- It can occur anywhere on the body that has subcutaneous adipose tissue, that’s the medical term for fat that accumulates just below the skin. This type of fat most commonly appears in the thighs and the buttocks.
- Although cellulite occurs when excess fat is deposited below the skin, one need not be obese or even overweight to develop cellulite. On the other hand, cellulite becomes more obvious with weight gain and improves in appearance with weight loss.
What is cellulite and why does it occur?
No one really knows for sure why cellulite occurs. Fibrous strands of collagen appear throughout the subcutaneous space between the skin and deeper structures of the body. Subcutaneous fat accumulates in between these fibrous strands. Some cellulite experts speculate that the orientation of these fibrous strands in women cause the fat to bulge (the medical term is herniate) into a weakened skin layer, called the dermis. This creates the appearance of dimples or valleys in between the hills of bulging, herniated fat. Others believe cellulite occurs after capillaries (tiny blood vessels) in the skin become leaky and allow fluid and other substances to be deposited below the skin. This excess fluid, or edema, is believed to compress blood vessels and lead to a decrease in oxygen flow to the area. This is supposed to cause a thickening of the fibrous strands interspersed between the water-logged fat. Increase in the size of fat cells and inflammation have also been suggested as possible causes of cellulite.
A recent paper by Michael van Vliet and colleagues reviews traditional and novel treatments for cellulite. It was also published in the Journal of Cosmetic and Laser Therapy (2005;7:7-10). Here is a brief overview of some commonly used treatments for cellulite:
Endermologie (LPG Systems, Valence France) has been around since the 1970s. It is an FDA approved device for the treatment of cellulite. Here is a brief description of how it works. A special electrically-powered hand-held device is used to suck folds of skin into the machine where it is kneaded by revolving rollers. (Doesn’t this conjures up images of a medieval torture device?). Typically, you have two 10-45 minute treatments over a period of a month or two. According to proponents, it takes about 10-20 treatments to get the best results. One or two per month are needed to maintain the results. A randomized, controlled trial, the gold standard of scientific studies, concluded that Endermologie was not effective in treating cellulite. However, 11 of 35 people treated did report thinking that they were improved. The study used a 10-minute treatment length, felt by some critics to be inadequate. They suggest 15-20 minute treatments as more appropriate.
Although traditional liposuction is effective at improving body contouring, it may in itself be associated with skin dimpling. Some experts have reported that ultrasonic liposculpturing may be better and safer than traditional liposuction. However, it is important to remember that liposuction is invasive and it is costly. Cellulite medical experts, such as Dr. Avram, remind us that it is still not a recommended treatment for cellulite.
This treatment involved inserting a hypodermic needle into the skin and moving it back and forth in order to disrupt the fibrous collagen strands felt responsible for skin dimpling. In one published study, over 78% of patients reporting being “satisfied” after one treatment. However, no objective criteria were used to assess improvement. Significant side effects, such as pain, bruising, skin darkening, and puckering, were reported. Tell me again, why I would want to have this treatment?
Mesotherapy: Injection of phosphatidylcholine and deoxycholate
Mesotherapy is supposed to disrupt cell membranes, dissolving fat. A study by Rose and Morgan demonstrated significant inflammation of fat tissue after injection of these substances. It is speculated that a reduction of subcutaneous fat will follow due to fat cell death and resorption. There are no studies to document improved appearance of cellulite.
A number of different substances have been promoted as treatments of cellulite. Cellasene, a mixture of Gingko biloba, sweet clover, grape seed oil, lecithin, and evening primrose oil, is widely promoted via the internet as a “miracle cure”. A controlled clinical study comparing Cellasene with an inactive (placebo) cream failed to demonstrate significant improvement after a two month treatment period. Of note, 7 of the 11 women using Cellasene gained weight during the study.
Aminophylline, a drug used to treat asthma, is felt by some to breakdown fat cells and fat cell clumping. One published study of topical aminophylline failed to demonstrate any positive effect on cellulite.
There are theoretical reasons why retinol may be useful in the treatment of cellulite. It is known to increase deposition of collagen dermis damaged by the sun. Since one of the proposed causes of cellulite is a weakened dermis that allows fat to bulge or herniated into it, it makes sense to test its efficacy in cellulite. Two placebo-controlled studies have been published. In one, 13 of 19 patients reported an improvement in the look and feel of the treated skin. The doctors who performed the studies also rated the skin’s appearance and their scores agreed with the subjective reports of the patients. Another study, an RCT—remember this is the gold standard of clinical studies—failed to demonstrate clinical improvement of overt cellulite after 6 months of treatment of 15 patients. There was, however, “some improvement” in patients with a milder form, called “incipient” or “mattress phenomenon-type” of cellulite.
VelaSmooth (Syneron Inc., Ontario, Canada) combines mechanical massage, continuous-wave radiofrequency, and near-infrared light laser treatment. Eight to 10 bi-weekly treatments are usually recommended. Thirty-five women treated with the VelaSmooth twice weekly for 8 to 16 weeks showed improvement in after 8 weeks and 70% were improved after 4 weeks. Improvement was measured as a significant reduction in thigh circumference. TriActive Laserdermology (Cynosure, Inc., Massachusetts) combines near-infrared laser treatment with local cooling and mechanical massage. The recommended course of treatment is three weekly treatments for two weeks and then twice weekly for four weeks. There are, as yet, no published data to support its efficacy.
It is fitting to close this discussion by pointing out that although obesity does not cause cellulite, it does become more obvious with weight gain. Weight loss improves the appearance of cellulite, and, of course, has health benefits that are more than cosmetic, particularly for individuals who are insulin resistant and develop high blood pressure and glucose intolerance when overweight or obese.
There are many other treatments not reviewed here that are being promoted to reduce cellulite. Googling “cellulite” returns almost 3 million hits, many of them companies hyping their miraculous products. It is impossible to address all of these, many of which will turn out, at best, to be useless and a complete waste of money. Some of these products have been documented to produce side effects, such as allergies, making the treatment worse than the having the cellulite.
Remember these points next time you think about plunking down your hard earned cash for something to get rid of cellulite:
- The majority of treatments, particularly “over the counter” treatments simply do not work.
- Some cause side effects.
- Cellulite can hardly be considered a disease or even a medical condition, given that almost every woman in the world has it. Isn’t that by definition normal?
- Weight loss will make you look better and it will make you feel better—best of all, it is free.
Postscript: For an entertaining discussion of the quackery that exists in the cellulite treatment arena, check out Stephen Barrett, MD’s discussion of “Cellulite” Removers on Quackwatch.org.
This blog was originally posted on the PEERtrainer website (www.peertrainer.com) on March 2, 2006.