A multilocus candidate approach identifies ACE and HIF1A as susceptibility genes for cellulite

A Clinical Guide to the Treatment of Cellulite and Comprehensive Review of the Etiology, Pathophysiology, and Utility of Intervention

INTRODUCTION

Cellulite is a common esthetic concern affecting most women. Despite its prevalence, there is no consensus on the optimal treatment approach for cellulite, partly due to the complex and multifactorial nature of its pathophysiology. Understanding the underlying biological processes along with available treatment options is important to be able to effectively counsel patients on effective management of this condition. This review aims to focus on high-quality evidence behind pathophysiology of cellulite, severity and grading, and its available treatment options.

METHODS

A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to pathophysiology, grading scales, and applications of treatment options were utilized.

RESULTS

Using the existing CSS classification, an evidence-based algorithm is proposed for treatment of cellulite. Mild cellulite is best served with lifestyle modifications such as healthy diet, hydration, and exercise. Use of topicals in mild cellulite patients as adjuncts to lifestyle modifications have the highest efficacy, although there are inconsistent data on topical treatments. Moderate cellulite is best targeted with noninvasive treatment options including laser therapy, radiofrequency, and ultrasound. Radiofrequency demonstrates the strongest efficacy in the current peer-reviewed literature. Severe cellulite is recommended to be treated with minimally invasive approaches such as subcision and injectables.

CONCLUSION

Cellulite is a challenging cosmetic problem to treat, and thus multimodal treatment options should be considered in an attempt to achieve optimal outcomes and patient satisfaction. As the pathophysiology of cellulite is further elucidated, more targeted treatments may be developed in the future.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Gluteal femoral subcutaneous and dermal adipose tissue in female

BACKGROUND

During the sexual maturation, gluteal femoral adipose tissue is subjected to numerous modifications, not observable in other regions, in particular in women and less in men. Other authors described this region, but they used imaging techniques having lower resolution, than MRI proposed in this study. High resolution imaging techniques might provide important and more detailed information about the anatomy of gluteal femoral region.

METHODS

This study has been performed using 7 T-magnetic resonance imaging and ultrastructural analysis in order to provide accurate description of the subcutaneous adipose tissue and dermis of gluteal femoral region. In this study specimens harvested from cadavers and form living patients have been analyzed.

RESULTS

The results showed the presence of three layers: superficial, middle, and deep, characterized by different organization of fat lobules. High resolution imaging showed the adipose papilla that originates from dermis and protrude in subcutaneous adipose tissue. Adipose papilla is characterized by a peculiar morphology with a basement, a neck and a head and these elements represent the functional subunits of adipose papilla. Moreover, ultrastructural study evidenced the relationship between adipocytes and sweat glands, regulated by lipid vesicles.

CONCLUSIONS

This study provides important information about subcutaneous and dermal fat anatomy of gluteal femoral region, improving the past knowledge, and move toward a better understanding of the cellulite physiopathology.

Cellulite: An Update on Pathogenesis and Management

Cellulite is a common cosmetic concern among postpubertal women. Despite its high prevalence, there have been only a few high-quality studies assessing its exact prevalence, risk factors, and pathophysiologic mechanisms. It has been difficult to achieve long-lasting results with the available treatments, including topical agents, energy-based devices, subcision, and injectables. In this review, the authors summarize the proposed etiologic factors, grading scales, and treatment options. Further well-designed studies are essential to improve our knowledge of the condition and lead to improved treatment strategies.

Update: Cellulite Therapies and Optimizing Treatment Combinations

Cellulite in the proximal lower extremities is a reported concern among many adult females. The unsightly appearance of cellulite leads many affected individuals to seek treatment by trained specialists. The objective of this review is to provide the reader with an update on new and innovative therapies for cellulite including various treatment combinations to maximize therapeutic outcomes, and strategies for minimizing adverse events. The availability of new technologies and the results from recent clinical trials provide additional tools and data to consider when creating treatment plans for cellulite patients. This update to previous treatment recommendations is based on the most recent developments in cellulite management including the personal experiences of the authors with an emphasis on injectable enzymes, acoustic subcision, targeted verifiable subcision, and biostimulators. Formal clinical studies are warranted to compare various treatment modalities and further investigate combination regimens.

LEVEL OF EVIDENCE: 5

Association of hypoxia inducible factor 1-Alpha gene polymorphisms with multiple disease risks: A comprehensive meta-analysis

HIF1A gene polymorphisms have been confirmed the association with cancer risk through the statistical meta-analysis based on single genetic association (SGA) studies. A good number SGA studies also investigated the association of HIF1A gene with several other diseases, but no researcher yet performed statistical meta-analysis to confirm this association more accurately. Therefore, in this paper, we performed a statistical meta-analysis to draw a consensus decision about the association of HIF1A gene polymorphisms with several diseases except cancers giving the weight on large sample size. This meta-analysis was performed based on 41 SGA study’s findings, where the polymorphisms rs11549465 (1772 C/T) and rs11549467 (1790 G/A) of HIF1A gene were analyzed based on 11544 and 7426 cases and 11494 and 7063 control samples, respectively. Our results showed that the 1772 C/T polymorphism is not significantly associated with overall disease risks. The 1790 G/A polymorphism was significantly associated with overall diseases under recessive model (AA vs. AG + GG), which indicates that the A allele is responsible for overall diseases though it is recessive. The subgroup analysis based on ethnicity showed the significant association of 1772 C/T polymorphism with overall disease for Caucasian population under the all genetic models, which indicates that the C allele controls overall diseases. The ethnicity subgroup showed the significant association of 1790 G/A polymorphism with overall disease for Asian population under the recessive model (AA vs. AG + GG), which indicates that the A allele is responsible for overall diseases. The subgroup analysis based on disease types showed that 1772 C/T is significantly associated with chronic obstructive pulmonary disease (COPD) under two genetic models (C vs. T and CC vs. CT + TT), skin disease under two genetic models (CC vs. TT and CC + CT vs. TT), and diabetic complications under three genetic models (C vs. T, CT vs. TT and CC + CT vs. TT), where C allele is high risk factor for skin disease and diabetic complications (since, ORs > 1), but low risk factor for COPD (since, ORs < 1). Also the 1790 G/A variant significantly associated with the subgroup of cardiovascular disease (CVD) under homozygote model, diabetic complications under allelic and homozygote models, and other disease under four genetic models, where the A is high risk factor for diabetic complications and low risk factor for CVD. Thus, this study provided more evidence that the HIF1A gene is significantly associated with COPD, CVD, skin disease and diabetic complications. These might be the severe comorbidities and risk factors for multiple cancers due to the effect of HIF1A gene and need further investigations accumulating large number of studies.

Infrared thermography as valuable tool for gynoid lipodystrophy (cellulite) diagnosis

Cellulite is a morphological alteration of the tegument tissue, directly interfering in self-esteem with etiology and pathophysiology far from being a consensus. Although the visual diagnosis of cellulitis is well known, it does not represent the real pathological condition of the subcutaneous tissue. The aim of the study was to investigate the hypothesis that the more heterogeneous tissue pattern analyzed by infrared thermography, the more severe is the cellulite grade. Forty female participants were selected and 60 thighs were analyzed by clinical anamnesis and infrared thermography. Classical visual analysis was correlated to the tissue heterogeneity measured by thermography. R Spearman's correlation between visual evaluation and thermography was 0.92. Phototype presented a negative significant correlation of 0.67 with classical visual analysis. In the present study, we presented a simple method based on infrared thermography that can be adopted in any esthetics office with a correlation of 0.92 with the visual classic evaluation, but, besides, may be very helpful to the clinician to decide which treatment will be adopted, i.e., an aggressive and inflammatory approach such as the radiofrequency of shockwave therapy or an anti-inflammatory approach such as photobiomodulation, depending on the inflammatory status of cellulite.

Effect of Three-Week Vibrotherapy on Selected Skin Parameters of Thighs and Buttocks in Women with Cellulite

Background: Cellulite (gynoid lipodystrophy, panniculopathy) affects approximately 85% of women and is related to genetic and hormonal factors, diet, and low physical activity. Vibrotherapy is a promising method of physical therapy to help fight cellulite that has not been studied exhaustively yet. Materials and Methods: Sixty healthy women (age: 19–43 years) with cellulite of at least grade I on the Nurnberg–Muller scale were recruited. The participants were randomly assigned to four groups, receiving a series of 15 vibration treatments in a sitting or lying position for 30 or 60 min. Before and after the first and last treatment, selected skin parameters were measured with the use of Courage and Khazaka equipment. Results: Skin hydration and transepidermal water loss (TEWL) of thighs and buttocks differed significantly at all time points. Post hoc tests showed that each treatment caused a decrease in TEWL but no long-term effect was observed. For skin pH, a significant difference was observed between the measurements I and IV. The lying position caused a greater reduction in the value of the acid–base balance. Conclusions: A series of vibration treatments improved the hydration and pH of the skin. The treatments limited TEWL; however, no long-term effect was observed.

Pilot study of histology aspect of cellulite in seventy patients who differ in BMI and cellulite grading

BACKGROUND

Cellulite is a topographic alteration of the skin with unknown etiology and is characterized by the presence of a dimpled or puckered aspect, as resembling an orange peel and cottage cheese or as having mattress-like appearance.

AIM

The aim of this research was to find the different histological aspect of cellulite in sixty patients.

MATERIALS AND METHODS

A total of 60 women, mean age 48.8 ( ± 11.08) were included in the study. Among these, 11 women were in menopause (18.33%). All patients after physical examination, aesthetic, and dermatological evaluation were subjected to five cellulite biopsies with a 2.0 mm diameter and 1.5 mm in length in the trochanteric region affected by cellulite. The descriptive statistics were performed for each study predictors demographic age, height, bmi, waist, belly, hip thigh, and knee.

RESULTS

The histological analysis of the stained slides showed five different histological features were present in the most of patient.

CONCLUSION

In conclusion, the outcome of this study shows that the histological evidence does not characterize the different states of cellulite, but several different histological aspects were present in the same patient, which effectively eliminates staging and could consider cellulite as a degenerative disease.

Prediction of potential deleterious nonsynonymous single nucleotide polymorphisms of HIF1A gene: A computational approach

Hypoxia-inducible factor-1α (HIF-1α) is the oxygen sensitive subunit of HIF1 transcription factor. Its variations is associated with several diseases including different type of cancer, cardiovascular diseases, and liver and kidney failure. Despite all the investigations carried out on the single nucleotide polymorphisms (SNPs) of HIF1A gene and diseases, there are many uncharacterized nonsynonymous SNPs of this gene, which might have damaging effect on the protein function. Therefore, it is worthwhile to analyze these potential damaging nsSNPs, using different bioinformatics tools before launching large population studies. The objective of the present study was to predict the possible deleterious nsSNPs of HIF1A gene and their effects on the function and structure of HIF-1alpha protein, using different bioinformatics tools. Various prediction servers were used including SIFT, PROVEAN, PolyPhen-2, PANTHER, phD-SNP, SNP-GO, I-Mutant 2.0, Fathmm, SNPeffect 4.0, Mutation taster, CADD and RAMPAGE in a stepwise approach. After analyzing all 454 missense variants of the HIF1A gene using the abovementioned tools, we reported 11 variants with a significant impact on the function or structure of HIF-1α protein. Furthermore, among these variants only S274 P was predicted as stability enhancing variant with effect on protein function by increasing its stability. Although there are many advantages for computational analysis, the results has to be confirmed by experimental investigations.

Characterization and Pharmacological Evaluation of Anti-Cellulite Herbal Product(s) Encapsulated in 3D-Fabricated Polymeric Microneedles

Skin health is vital for a healthy body. Herbal remedies have long been used for skin care, and their global use has tremendously increased over the past three decades. Although cellulite is seen as a normal condition by the medical community, it is considered a serious cosmetic concern for most affected women. Many topical anti-cellulite creams are available on the market, but unfortunately, their efficacy has not been proven scientifically. Microneedles (MNs) represent a new approach to enhance the permeation of loaded medication through the skin. In this study, the anti-cellulite effects of Vitex agnus-castus and Tamarindus indica extracts were compared using safe and effective polymeric MNs. This delivery system offers a painless alternative to the combined treatment strategy of microneedling devices and anti-cellulite products. The selected standardized extracts were evaluated for their mineral, phenolic and flavonoid contents, which are correlated to a promising antioxidant effect, as demonstrated by an in vitro radical scavenging activity assay. 3D-printing techniques were chosen for fabrication of a micromold, which is inexpensive for mass production. To ensure that MNs were sufficiently strong to perforate the skin without breaking, axial failure force was measured using a micro-mechanical test machine. The anticellulite effects of MNs were assessed using an in vivo diet-induced obesity guinea pig model. Skin properties, histopathology and inflammatory markers were examined. MNs loaded with plant extracts were statistically comparable in normalizing the oxidative state and reducing inflammation, while myeloperoxidase levels were more significantly reduced by T. indica than by V. agnus-castus. This novel delivery system opens the door for new transdermal strategies for cellulite management.

Cellulite: a cosmetic or systemic issue? Contemporary views on the etiopathogenesis of cellulite

Cellulite (also known as gynoid lipodystrophy or orange peel syndrome) is one of the most common lipodystrophy syndromes, which affects millions of post-adolescent women. Cellulite is manifested by topographic disorders of subcutaneous tissue such as nodules, edema, and abnormal fibrosis. It is located mainly on the pelvic area, especially on the buttocks. Its pathogenesis is complexed and unclear. There are several theories about its pathophysiology. Hormonal disorders, endothelial dysfunction and genetic predispositions are taken under consideration.

The Effect of Combination of Red, Infrared and Blue Wavelengths of Low-Level Laser on Reduction of Abdominal Girth: A Before-After Case Series

Introduction: The objective of this study was to assess the efficacy of a combination of 3 wavelengths (including red, infra-red, and blue) of low-level laser (LLL) as a non-invasive therapeutic method to reduce abdominal girth. To achieve biochemical activity on adipocytes, a red laser was used in our selective laser combination. Near-infrared laser was used to increase depth of penetration. Nitrosyl complexes of hemoglobin (NO-Hb) are sensitive to blue light, thereby leading to increase in release of biologically active nitric oxide (NO), which can affect tissue perfusion. Thus, a blue LED was added to the laser combination. Methods: Eighteen females participated in the study. Twelve sessions of laser therapy were performed, 2 sessions per week for each subject. Continuous wave diode lasers, including red (630 nm), infra-red (808 nm), and a blue LED (450 nm) were applied and were all designed by the Canadian Optic and Laser Center. Results: Statistical analyses revealed that upper abdomen size significantly decreased from pre- (91.86 ± 11.16) to post- (87.41 ± 10.52) low-level laser therapy (LLLT) (P<0.001). Middle abdomen size showed significant reduction from pre- (97.02 ± 8.82) to post- (91.97 ± 8.49) LLLT (P<0.001). Lower abdomen size significantly decreased from pre- (100.36 ± 9.45) to post- (95.80 ± 8.52) LLLT (P<0.001). Conclusion: Based on this case series pilot investigation, the combination of 3 different wavelengths of LLL was effective for abdominal girth reduction in 100% of our subjects (P<0.001), without any side effects. Future studies will assess the long-term benefits of this laser combination for reduction of subcutaneous fat deposits.

HIF1A gene polymorphisms and human diseases: Graphical review of 97 association studies

Hypoxia-inducible factors (HIFs) belong to a family of transcription factors (TF) responsive to a low O2 availability, which is often a characteristic feature of solid tumors. The alpha subunit of the HIF heterodimer is O2 -sensitive, and once stabilized in hypoxia, it functions as a master regulator of various genes involved in hypoxia pathway. Changes in the HIF1A (hypoxia inducible factor 1, alpha subunit) nucleotide sequence or expression has been shown to be associated with the development of several diseases. Because of increasing research interest in HIF1A gene a review of association studies was needed. We here reviewed published data on single nucleotide polymorphisms (SNPs) in HIF1A in various diseases; in total, 34 SNPs were tested for an association with 49 phenotypes, and the results were visualized using the Cytoscape software. Among all collected polymorphisms 16 SNPs showed significant associations with 40 different phenotypes, including six SNPs associated with 14 cancer types. Missense SNPs (rs11549465 and rs11549467) within the oxygen-dependent degradation domain were most frequently studied. The study provides a comprehensive tool for researchers working in this area and may contribute to more accurate disease diagnosis and identification of therapeutic targets.

Cellulite: a review with a focus on subcision

Cellulite is an alteration in skin topography most often found on the buttocks and posterolateral thighs of the majority of postpubertal females. This article aims to review the background, potential pathophysiology, and potential treatment options for cellulite, highlighting subcision as an ideal therapeutic option for this cosmetically distressing condition.

Nucleic acid delivery into skin for the treatment of skin disease: Proofs-of-concept, potential impact, and remaining challenges

Nucleic acids (NAs) hold significant potential for the treatment of several diseases. Topical delivery of NAs for the treatment of skin diseases is especially advantageous since it bypasses the challenges associated with systemic administration which suffers from enzymatic degradation, systemic toxicity and lack of targeting to skin. However, the skin's protective barrier function limits the delivery of NAs into skin after topical application. Here, we highlight strategies for enhancing delivery of NAs into skin, and provide evidence that translation of topical NA therapies could have a transformative impact on the treatment of skin diseases.

Association and Prognostic Significance of the Functional -1562C/T Polymorphism in the Promoter Region of MMP-9 in Turkish Patients with Gastric Cancer

Matrix metalloproteinases (MMPs) are a group of zinc-dependent peptidases that participate in matrix turnover in solid malignancies. The aim of this study was twofold. First, we sought to investigate under a case-control design the association between the functional -1562C/T polymorphism in the promoter region of MMP-9 and gastric cancer (GC) in a Turkish sample. Second, we examined its prognostic significance in GC patients. A total of 144 subjects were enrolled in the case-control study (79 GC cases and 65 controls). Overall survival (OS) and progression-free survival (PFS) served as the main outcome measures in the longitudinal study. The MMP-9 -1562C/T polymorphism was genotyped using a polymerase chain reaction-restriction fragment length polymorphism method. The odds ratio (OR) of GC for the CC genotype relative to the CT+TT genotypes was not significant (OR = 0.89, 95 % confidence interval [CI] = 0.44-1.82, P = 0.75). These results did not change after allowance for age and sex in multivariable regression analysis (OR = 0.81, 95 % CI = 0.40-1.94, P = 0.84). When the MMP-9 -1562C/T polymorphism was analyzed among GC patients in relation to OS and PFS, we found no significant differences between subjects with the CC and CT+TT genotypes. In conclusion, the results of our study did not point toward a major role of the MMP-9 -1562C/T polymorphism in the pathogenesis and clinical course of GC in Turkish subjects.

Cellulite: advances in treatment: facts and controversies

Cellulite is traditionally considered a highly prevalent aesthetic condition in women. From a clinical standpoint, it is characterized by a cottage-cheese-like appearance of the skin, which can be most commonly found in certain areas of the body (eg, thighs, buttocks, and legs). Although cellulite is generally asymptomatic, the more severe stages can be accompanied by the appearance of painful nodules and increased local temperature, which are suggestive of an inflammatory reaction occurring in the dermis and in the underlying subcutaneous adipose tissue. Whether cellulite is a real disease or only a disturbing aesthetic issue is still a matter of controversy. This debate notwithstanding, it seems clear from market trends that there is considerable commercial interest in developing effective strategies aimed at reducing the cottage-cheese-like appearance of cellulite areas. Quite disturbingly, the majority of treatment attempts to date have been conducted in an empirical manner and without the application of rigorous scientific methodology. This is likely due--at least in part--to the lack of major, evidence-based pathophysiological insights into the nature of this condition. More stringent regulatory control is needed over commercial products aiming at improving the appearance of cellulite.

Predictability of the individual clinical outcome of extracorporeal shock wave therapy for cellulite

BACKGROUND

Extracorporeal shock wave therapy has been successfully introduced for the treatment of cellulite in recent years. However, it is still unknown whether the individual clinical outcome of cellulite treatment with extracorporeal shock wave therapy can be predicted by the patient's individual cellulite grade at baseline, individual patient age, body mass index (BMI), weight, and/or height.

METHODS

Fourteen Caucasian females with cellulite were enrolled in a prospective, single-center, randomized, open-label Phase II study. The mean (± standard error of the mean) cellulite grade at baseline was 2.5±0.09 and mean BMI was 22.8±1.17. All patients were treated with radial extracorporeal shock waves using the Swiss DolorClast(®) device (Electro Medical Systems, S.A., Nyon, Switzerland). Patients were treated unilaterally with 2 weekly treatments for 4 weeks on a randomly selected side (left or right), totaling eight treatments on the selected side. Treatment was performed at 3.5-4.0 bar, with 15,000 impulses per session applied at 15 Hz. Impulses were homogeneously distributed over the posterior thigh and buttock area (resulting in 7,500 impulses per area). Treatment success was evaluated after the last treatment and 4 weeks later by clinical examination, photographic documentation, contact thermography, and patient satisfaction questionnaires.

RESULTS

The mean cellulite grade improved from 2.5±0.09 at baseline to 1.57±0.18 after the last treatment (ie, mean δ-1 was 0.93 cellulite grades) and 1.68±0.16 at follow-up (ie, mean δ-2 was 0.82 cellulite grades). Compared with baseline, no patient's condition worsened, the treatment was well tolerated, and no unwanted side effects were observed. No statistically significant (ie, P<0.05) correlation was found between individual values for δ-1 and δ-2 and cellulite grade at baseline, BMI, weight, height, or age.

CONCLUSION

Radial shock wave therapy is a safe and effective treatment option for cellulite. The individual clinical outcome cannot be predicted by the patient's individual cellulite grade at baseline, BMI, weight, height, or age.

An integral topical gel for cellulite reduction: results from a double-blind, randomized, placebo-controlled evaluation of efficacy

BACKGROUND

Cellulite is a serious cosmetic concern for most of the 90% of women affected by it.

OBJECTIVE

To assess the clinical efficacy of a complex integral anti-cellulite gel.

METHODS

This double-blind, randomized, placebo-controlled study involved 44 healthy women, aged 25-55 years. Subjects had a normal to slightly overweight body mass index and presented slight to moderate cellulite on their thighs, buttocks, and/or hips at baseline. Subjects were randomly assigned to either the treated or placebo group and accordingly applied the active product or placebo on their hips, stomach, buttocks, and thighs, twice daily for 3 months. Skin tonicity, orange-peel aspect, and stubborn cellulite were assessed at day 0, 28, 56, and 84. A self-evaluation questionnaire was completed by all volunteers.

RESULTS

At the end of the study, an average of 81% of the subjects applying the active product presented improvement in their cellulite condition versus 32% for the placebo group (all descriptors and sites combined). At day 84, skin tonicity, orange-peel appearance, and stubborn cellulite were improved in a significant manner (P<0.05) over placebo, on all studied areas. Skin tonicity improved on average by +41% for buttocks, +35% for hips, and +31% for thighs. Orange peel appearance was reduced on average by -25% for buttocks, -22% for hips, and -22% for thighs. Stubborn cellulite was reduced on average by -19% for buttocks, -24% for hips, and -22% for thighs. Circumference measurements decreased in a significant manner (P<0.05) over placebo, for the abdomen (average value of -1.1 cm) and thighs (average value of -0.8 cm). The product was well tolerated and perceived by the volunteers themselves as better performing than placebo on all criteria.

CONCLUSION

All results validate the efficacy of the present integral formulation to significantly reduce signs of cellulite and reshape the silhouette.

Dietary supplementation with polyphenol-rich chokeberry juice improves skin morphology in cellulite

The aim of our study was to investigate possible beneficial effects of organic chokeberry juice (OCJ) consumption in the treatment of cellulite. Twenty-nine women aged 25-48 with a cellulite grade 2 according to the Nurnberger-Muller scale were included. Anthropometric and biochemical parameters were measured. Skin structure was analyzed by ultrasonography. All subjects consumed 100 mL of OCJ per day, during 90 days. Measurements of investigated parameters were performed at 0, 45, and 90 days of the study. A marked reduction in the subcutaneous tissue thickness was observed in all subjects, with the average reduction of 1.9 mm. The length of subcutaneous tissue fascicles (ScTFL) was reduced in 97% (28 out of 29) of subjects, with the average value of 1.18 mm. After 45 days of chokeberry juice consumption, reduction of edema was observed in 55.2% of the subjects with edema at the baseline, while at the endpoint of the study, edemas were not observed in any of the subjects involved in the study. OCJ could have beneficial effects on the cellulite condition, including the length of ScTFL, subcutaneous tissue, and dermis thickness as well as on edema reduction.

Cellulite's aetiology: a review

Cellulite, highly prevalent among women, represents a serious problem for many of them, and one of their main aesthetic concerns. It is difficult to pinpoint its aetiology and physiology/pathophysiology, as there are many factors that are involved in it, affect it, and many processes that are taking place simultaneously and sequentially. Our objective is therefore, to review the scientific scholarship on cellulite to explore the causes of its origin. We carried out a preliminary search of the Medline, Cochrane, and Web of Knowledge databases covering the period from 1978 to April 2011. As there is no specific key word for the phenomenon at hand, we used the following descriptors: adipose tissue, subcutaneous fat, subcutaneous tissue, connective tissue, skin, skin disease and dermis. This resulted in a retrieval of 26 articles contributing to relevant information on the aetiology of cellulite. As a result of our first research, we concluded that cellulite is a physiological phenomenon or at least, that it has a physiological origin, which is characteristic of women, and multi-causal, with the coexistence of a number of factors that trigger, perpetuate, or exacerbate it. The outstanding factors include, among others, connective tissue architecture, oestrogen action, microvascular alterations and certain genetic and hormonal characteristics. All of them provide us with future and novel clues to cellulite treatment, and is necessary to take some or all of these factors into account in developing an effective therapy. However, we are aware of the necessity of further investigation in this field.

Effect of cosmetic ingredients as anticellulite agents: synergistic action of actives with in vitro and in vivo efficacy

BACKGROUND

The pathophysiology of cellulite involves changes in the subcutaneous adipose layer and the extracellular matrix (ECM) that supports it together with overlying dermal layer. Cellular mechanisms governing cellulite are not fully understood. However, it is accepted that changes include enhanced lipogenesis, decreased lipolysis, and increased lipid storage within the adipocytes as well as changes in the dermal architecture.

AIM

In our studies the ability of cosmetic agents Furcellaria lumbricalis, Fucus vesiculosus, retinoid, conjugated linoleic acid (CLA), and a glaucine mixture to stimulate in vitro 1) lipolysis in human adipocytes and 2) production of pro-collagen I by fibroblasts was investigated in vitro. The ability of these ingredients to improve cellulite condition in vivo was also determined.

PATIENTS/METHODS

Mature adipocytes and 'aged' fibroblasts were used for in vitro studies. The assessment of cellulite in vivo was performed by dermatological grading and ultrasound measurements.

RESULTS

Mature adipocytes treated with combined actives resulted in a significant synergistic increase in free glycerol release. On "aged" fibroblasts, combined treatment of F. vesiculosus and F. lumbricalis stimulated pro-collagen I production. CLA increased pro-collagen I production, but the glaucine mixture had no effect. The clinical study demonstrated a significant improvement in cellulite grading by a dermatologist after 8 and 12 weeks vs. vehicle, and ultrasound imaging showed a significant decrease in fat thickness compared with placebo after 12 weeks.

CONCLUSIONS

Our studies revealed a potent cocktail of ingredients that when combined together can act in vitro to markedly improve lipolysis mechanisms and by way of stimulating pro-collagen I can also have an effect on the surrounding extracellular matrix. The in vitro actions of the ingredients were translated in vivo, where a clinical improvement of cellulite condition was observed.

Adiponectin expression in subcutaneous adipose tissue is reduced in women with cellulite

BACKGROUND

Cellulite, which appears as orange peel-type or cottage cheese-like dimpling of the skin on the thighs and buttocks, is a complex, multifactorial, cosmetic disorder of the subcutaneous fat layer and the overlying superficial skin. Adiponectin is an adipocyte-derived hormone mainly produced by subcutaneous fat that shows important protective anti-inflammatory and vasodilatory effects. We hypothesized that adiponectin expressed in the subcutaneous adipose tissue (SAT) might play a role in the pathogenesis of cellulite. We reasoned that a reduction in the expression of adiponectin - a humoral vasodilator - in the SAT of cellulite areas might contribute to the altered microcirculation frequently found in these regions.

METHODS

A total of 15 lean (body mass index [BMI] < 25 kg/m(2) ) women with cellulite and 15 age- and BMI-matched women without cellulite participated in this study. Real-time reverse transcription polymerase chain reaction (RT-PCR) was used to assess adiponectin gene expression. Plasma adiponectin levels were measured using a commercial enzyme immunoassay kit.

RESULTS

Adiponectin mRNA expression in the SAT of the gluteal region was significantly lower in areas with cellulite compared with those without (12.6 ± 3.1 AU versus 16.6 ± 4.1 AU; P=0.006). However, plasma adiponectin levels did not differ between women with (20.3 ± 7.3 μg/ml) and without (19.3 ± 6.1 μg/ml) cellulite (P=0.69).

CONCLUSIONS

Adiponectin expression is significantly reduced in the SAT in areas affected by cellulite. Our findings provide novel insights into the nature of cellulite and may give clues to the treatment of this cosmetic issue.

Evaluation of the prevalence of concomitant idiopathic cyclic edema and cellulite

The aim of this study was to evaluate the prevalence of concomitant idiopathic cyclic edema with Grade II and III cellulite. All patients treated for Grade II and III cellulite were evaluated for idiopathic cyclic edema in a retrospective, quantitative and cross-sectional study. The study was carried out at the Godoy Clinic in the period from 2006 to 2010. All patients with body mass indexes > 25, Grade I cellulite and other causes of edema were excluded. The diagnosis of idiopathic cyclic edema was based on a clinical history and fluid retention throughout the day, in particular difficulty in removing rings on waking in the morning which improves later in the day. All patients with cyclic edema were treated with 75 mg aminaphtone three times daily. Statistical analysis considered the frequency of edema. Of the 82 women evaluated with ages between 18 and 58 years old (mean of 34.9 years) 41 (50.0%) were diagnosed with idiopathic cyclic edema. Idiopathic cyclic edema is an aggravating factor for cellulite and is frequently associated with the more advanced stages of the disease. Its control is essential in the treatment of cellulite.