Cellulite Reduction by Modified Thai Herbal Compresses; A Randomized Double-Blind Trial

Comparative Analysis of Cellulite Treatment Modalities: A Systematic Review

BACKGROUND

Cellulite is a highly prevalent and aesthetically distressing skin condition. Whilst there are a variety of treatment modalities, none are definitively established.

OBJECTIVE

This systematic review aims to assess invasive and noninvasive treatment modalities for cellulite management.

METHODS

The review protocol was published and registered a priori (PROSPERO CRD42022359334). A comprehensive electronic search for relevant randomised controlled trials, (RCTs) was performed in CENTRAL, MEDLINE, Embase and Web of Science databases. Study quality and risk of bias were assessed using Cochrane's risk of bias tool, respectively.

RESULTS

Overall, 753 studies were initially identified, of which 24 randomised controlled trials (RCTs) satisfied the eligibility criteria with a total of 2084 patients with a mean follow-up of 3.33 ± 13.4 weeks. Evaluated interventions included mechanical stimulation, topical therapy, shock wave therapy (SWT), laser and light-based devices, radiofrequency therapy, subcutaneous injectables, and ultrasound. SWT emerged as a standout intervention, demonstrating a consistent cellulite reduction score of 2.07 ± 0.39 across four studies. Radiofrequency therapy exhibited a statistically significant reduction of thigh circumference (- 2.09 cm, p < 0.001) and subcutaneous tissue thickness (- 2.23 cm, p < 0.001). Subcutaneous injectables, specifically collagenase Clostridium histolyticum-aaes, demonstrated a statistically significant improvement in the clinician-reported photonumeric cellulite severity scale (17.0%) and patient-reported photonumeric cellulite severity scale (25.7%) (p < 0.001). The overall quality of the studies using the grading of recommendations, assessment, development and evaluation approach was moderate.

CONCLUSION

This is the first methodologically robust systematic review evaluating interventions for cellulite. SWT, radiofrequency therapy, and subcutaneous injectables have shown promising findings in cellulite treatment.

LEVEL OF EVIDENCE I

The journal asks authors to assign a level of evidence to each article. For a complete description of Evidence-Based Medicine ratings, see the Table of Contents or the online Instructions for Authors at www.springer.com/00266 .

Cellulite: Presentation and Management

Cellulite is a common dermatological condition with a female preponderance, affecting up to 90% post-pubertal females. It is characterized with dimpling and denting of the skin surface, giving it a Peau d'orange appearance. Once considered to be a benign physiological isolated skin condition of only an aesthetic concern, cellulite is now considered a pathological entity with systemic associations and a negative psychological impact on patients. Several treatment options from lifestyle modifications, topical cosmetic therapies to energy-based devices have been studied for its treatment. However, treatment remains a challenge despite many new modalities in the armamentarium. Laser and light therapies along with radiofrequency are useful treatment options with good safety profile. Acoustic wave therapy, subcision, and 1440-nm Nd:YAG minimally invasive laser are beneficial in cellulite reduction. Methodological differences in the trials conducted, makes it difficult to compare different treatment modalities. Overall, treatment needs to be individualized based on the patient characteristics and severity of the condition. Combination of treatments is often required in most patients for reducing cellulite.

Development, Characterization, and Stability Evaluation of the Anti-Cellulite Emgel Containing Herbal Extracts and Essential Oils

Recently, the herbal compress was successfully developed and applied for cellulite treatment. The aim of this study was to formulate a more convenient dosage form of herbal application from the original formula. In addition, we aimed to characterize and evaluate the stability of the developed dosage form. A gelled emulsion, or an “emgel,” incorporated with 0.1 wt% tea and coffee extracts (1:1 ratio) plus 5 wt% essential oils (mixed oil) was prepared. The caffeine content in the finished product obtained from tea and coffee extracts analyzed by HPLC was 48.1 ± 2.3 µg/g. The bio-active marker monoterpenes of mixed oil characterized by headspace GCMS were camphene 50.8 ± 1.8 µg/mg, camphor 251.0 ± 3.2 µg/mg, 3-carene 46.7 ± 1.8 µg/mg, α-citral 75.0 ± 2.1 µg/mg, β-citral 65.6 ± 1.3 µg/mg, limonene 36.8 ± 6.7 µg/mg, myrcene 53.3 ± 4.5 µg/mg, α-pinene 85.2 ± 0.6 µg/mg, β-pinene 88.4 ± 1.1 µg/mg, and terpinene-4-ol 104.3 ± 2.6 µg/mg. The stability study was carried out over a period of 3 months at 4, 25, and 50 °C. The caffeine content showed no significant changes and passed the acceptance criteria of ≥80% at all tested temperatures. However, monoterpenes showed their stability for only 2 months at 50 °C. Therefore, the shelf-life of the emgel was, consequently, calculated to be 31 months using the Q10 method. Thus, the anti-cellulite emgel was successfully formulated. The characterization methods and stability evaluation for caffeine and monoterpenes in an emgel matrix were also successfully developed and validated.

Efficacy of an Anti-Cellulite Herbal Emgel: A Randomized Clinical Trial

Cellulite describes unsightly skin overlying subcutaneous fat around thighs and buttocks of post-pubescent females. A herbal ‘emgel’ containing volatile oils and extracts of A traditional Thai herbal compress was tested in a double-blind, placebo-controlled trial with 18 women aged 20–50 year with severe cellulite. Appearance of cellulite (primary outcome), thigh circumferences, skin firmness, and cutaneous blood flow (secondary outcomes) were assessed at baseline, 2, 4, 8 and 12 weeks with a 2-week follow-up. Herbal emgel applied onto the thigh skin twice daily reduced cellulite severity scores in every time point. The score was reduced from 13.4 ± 0.3 (baseline) to 12.1 ± 0.3 (week 2) and 9.9 ± 0.6 (week 12). All secondary outcomes improved with both placebo and herbal emgels suggesting that ingredients in the base-formulation might be responsible. Querying of participants, analysis of their diaries, and physical monthly inspections found no adverse events. The herbal emgel safely improved the appearance of cellulite, while the base emgel may play a role for other endpoints. Further studies on the active constituents and their mechanism of action are needed to further explore these factors.

Effects of Essential Oils and Some Constituents from Ingredients of Anti-Cellulite Herbal Compress on 3T3-L1 Adipocytes and Rat Aortae

Cellulite is associated with a complex array of adipocytes under the skin and vascular system. A herbal compress that was previously developed was proven to have an anti-cellulite effect in healthy volunteers within 2 weeks of treatment. However, its mechanism and ingredients responsible for reducing cellulite were not known. The purpose of this study was to investigate the activity of eight essential oils in, and two water extracts from, the ingredients of the herbal compress together with nine monoterpenoid constituents on the 3T3-L1 adipocytes. The vasodilatory effect on rat aortae was also studied. The adipocytes were induced by dexamethasone, 3-isobutyl-1-methylxanthine and insulin. At all concentrations tested, all essential oils, water extracts and their monoterpenoid constituents significantly inhibited lipid accumulation activity (p < 0.05) and decreased the amount of triglycerides when compared to untreated cells (p < 0.01). In addition, our results showed that the mixed oil distilled from the herbal compress mixed ingredients could relax the isolated rat aorta (EC₅₀ = 14.74 ± 2.65 µg/mL). In conclusion, all essential oils, extracts and chemical constituents tested showed effects on adipogenesis inhibition and lipolysis induction on the cultured adipocytes with the mixed oil demonstrating vasorelaxation activity, all of which might be the mechanisms of the anti-cellulite effects of the herbal compress.

Insights Into the Pathophysiology of Cellulite: A Review

BACKGROUND

The etiology of cellulite is unclear. Treatment of cellulite has targeted adipose tissue, dermis, and fibrous septae with varying degrees of success and durability of response.

OBJECTIVE

Results from clinical trials that target different anatomical aspects of cellulite can provide insights into the underlying pathophysiology of cellulite.

MATERIALS AND METHODS

A search of the PubMed database and ClinicalTrials.gov website was conducted to identify clinical trials that have investigated treatments for cellulite.

RESULTS

A lack of trial protocol standardization, objective means for quantification of improvement and reported cellulite severity, and short-term follow-up, as well as variation in assessment methods have made comparisons among efficacy studies challenging. However, the lack of durable efficacy and inconsistency seen in clinical results suggest that dermal or adipose tissue changes are not the primary etiologies of cellulite. Clinical studies targeting the collagen-rich fibrous septae in cellulite dimples through mechanical, surgical, or enzymatic approaches suggest that targeting fibrous septae is the strategy most likely to provide durable improvement of skin topography and the appearance of cellulite.

CONCLUSION

The etiology of cellulite has not been completely elucidated. However, there is compelling clinical evidence that fibrous septae play a central role in the pathophysiology of cellulite.