Moderate Cellulite Research Articles

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

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. 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. 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. 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. 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 .

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Clostridium histolyticum (CCH-aesthetic formulation [CCH-aaes]) is a recently approved, targeted enzymatic treatment for cellulite in the buttock. Cellulite also develops in thighs, and the treatment areas require different injection techniques and product dilutions. This Phase 4 study aims to assess the effectiveness of multiple concentrations of CCH-aaes for the concomitant treatment of mild to moderate cellulite in the buttock and thighs of adult females. Cellulite severity was assessed using the Investigator Global Aesthetic Improvement Scale (I-GAIS) on days 1, 22, 43, and 90, and the Body-Q appraisal of cellulite and the Clinician Reported-Photonumeric Cellulite Severity Scale (CR-PCSS) on days 1 and 90. Treatments were performed on buttock and thigh dimples on days 1, 22, and 43 with reference to a provided calculation matrix, which is based upon the reconstitution, dilution, and injection patterns and volumes identified as optimal for these distinct areas by early research endeavors. The matrix permits customization to the desired number and location of cellulite dimples to be treated. Among the 5 subjects treated, 3 experienced improvement of cellulite severity in both treatment areas as measured by all 3 scales, and 2 participants showed improvement or no change in CR-PCSS and Body-Q Appraisal of Cellulite and worsening I-GAIS scores for one or both treatment areas. This study suggest that use of CCH-aaes in the concurrent treatment of the thigh and buttocks is predictable and efficacy and safety are similar for both areas.

Outpatient management of moderate cellulitis in children using high-dose oral cephalexin.

To evaluate the effectiveness of a high-dose (HD) oral cephalexin treatment guideline for children with moderate cellulitis treated as outpatients. In this retrospective cohort study, we included children who presented to the emergency department (ED) with moderate cellulitis and treated according to the institution's HD oral cephalexin guideline over a 2-year period. All children had standardized follow-up at a medical day hospital (MDH). Treatment was considered effective in the absence of treatment failure, defined as admission, switch to IV treatment or ED visit within 2 weeks of discharge from the MDH. Safety was ascertained by recording adverse events and severe complications at follow-up. A total of 123 children were treated as outlined in the guideline, including 117 treated with HD oral cephalexin. The success rate was 89.7% (105/117). Among 12 (10.3%) children who had treatment failure, 10 (8.5%) required admission, 1 (0.9%) received IV antibiotics at the MDH and 1 (0.9%) had a return visit to the ED without admission. No severe complications were reported; four abscesses required drainage and one patient had a rash. The mean number of visits per child at the MDH was 1.6 (SD 1.0). With a success rate of 89.7%, HD oral cephalexin seems effective and safe for the treatment of children with moderate cellulitis. Its use potentially reduces hospitalization rates for this condition and decreases the need for IV insertion.

Microwave Therapy for Cellulite: An Effective Non-Invasive Treatment.

Background: Cellulite represents a common cosmetic problem that affects nearly all women. This study aimed to evaluate microwave therapy’s effectiveness for cellulite treatment. Methods: In this study, 26 women showing severe or moderate cellulite underwent four sessions of microwave therapy on the buttocks and posterior thighs. The following assessments were performed at baseline and the three-month follow-up after the last treatment: the Cellulite Severity Scale (CSS), Nürnberger–Müller classification scale, photographic evaluation, and buttocks/posterior thighs circumference measurements. A Likert scale questionnaire was used to assess patient satisfaction at the 3-month follow-up. Results: The treatment positively affected the cellulite severity as confirmed by the Cellulite Severity Scale (CSS) and Nürnberger–Müller classification scale results. CSS showed a significant amelioration in cellulite severity between the initial assessment and the 3-month follow-up for the buttocks and posterior thighs, with total average scores that ranged from 10.7 ± 3.1 to 4.5 ± 1.8 (p < 0.01). The treatment also resulted in a remarkable improvement in comfort/satisfaction and a buttocks and posterior thighs circumference reduction. No serious adverse events were observed. Conclusions: Microwave therapy has proven to be a safe treatment for improving cellulite appearance and reducing body circumferences.

193. quality Improvement Initiative for Non-purulent Cellulitis Management in Urgent care setting: provider-level Performance Feedback

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) has emerged as a common cause of skin and soft-tissue infections (SSTIs). This has resulted in an 88% increase in MRSA-directed antibiotic use in emergency departments. However, the majority of cellulitis presents as non-purulent due to Group A streptococci. An unintended consequence is that many with non-purulent cellulitis receive sub-optimal antibiotics and unnecessary diagnostics. Clinical guidelines at our institution recommend beta-lactam antibiotics and discourage empiric MRSA coverage for non-purulent cellulitis. The aim of this study is to use an audit-feedback intervention to optimize urgent care providers management of mild/moderate non-purulent cellulitis.MethodsWe identified all consecutive patients presenting to our urgent care with a diagnosis of lower extremity non-purulent cellulitis using ICD coding. We conducted a prospective pre and post-intervention study from 10/2018-3/2019 and 11/2019-4/2020 respectively. Intervention included review of practice guidelines with providers and feedback from pre-intervention phase. To assess individual practitioners’ prescribing habits, a comprehensive scoring system focused on empiric antibiotic selection, antibiotic duration, and diagnostics was combined with patient demographics. Scores classified non-purulent SSTI treatment as follows: 0–2 = good, 2.5–5 = fair, and >5.5 = poor (Figure 1).Figure 1: Provider Cellulitis Management Scoring Sheet ResultsThere was statistically significant provider score improvement in the post-intervention phase with greater percentage of good cases (40% to 69%) and no poor cases (Figure 2). For IV antibiotics for mild and moderate cellulitis, there was decreased use of overly broad antibiotics (Figure 3). Antibiotic duration of greater than 7 days decreased from 68% to 52%. Combination antibiotic therapy decreased from 12% to 4%. There was also a statistically significant decrease in use of wound cultures but no change in ultrasound use.Figure 2: Overall Provider Scores Figure 3: IV Antibiotic Use ConclusionAudit-feedback intervention was effective for improving antibiotic usage and decreasing treatment duration. Providing physicians with data on their practice patterns relative to those of their peers and clinical practice guidelines can improve management of non-purulent cellulitis.Disclosures All Authors: No reported disclosures

Effects of transcutaneous electrical nerve stimulation on pain intensity during application of carboxytherapy in patients with cellulite: A randomized placebo-controlled trial.

Carboxytherapy may generate local pain that is considered the main limiting factor in clinical practice. Transcutaneous electric nerve stimulation (TENS) is widely used in the control of acute pain; however, the effect of TENS on pain relief during carboxytherapy has not been studied to date. To assess the effect of TENS on pain intensity during carboxytherapy in patients with cellulite in the gluteal region. This randomized clinical trial was conducted with 84 patients, 18-44 years of age, who had moderate cellulite in the gluteal region, according to Cellulite Severity Scale, but never received carboxytherapy. Patients were randomized into 3 groups: active TENS, placebo TENS, and control group. For the intervention, skin depressions with cellulite were outlined, and the gluteal area to be treated was defined. The subcutaneous injection of CO2 was performed using 0.30 × 13 mm-needles at a 45° angle, with a controlled flow rate of 100 mL/min maintained for 1 minute at each puncture site. The parameters for TENS were as follows: frequency of 100 Hz and pulse duration of 200 μs; TENS intensity was adjusted until the patient reported strong paresthesia. The visual numeric pain rating scale was used to assess pain intensity after each puncture. The active TENS group reported lower pain intensity compared to the placebo TENS (P < .0001) and control (P < .0001) groups. Transcutaneous electric nerve stimulation (TENS) was effective in reducing pain intensity during carboxytherapy in patients with cellulite in the gluteal region.

LO26: The efficacy of high dose cephalexin in the outpatient management of moderate cellulitis for pediatric patients

Introduction: Children with moderate cellulitis are often treated with IV antibiotics in the hospital setting, as per recommendations. Previously in our hospital, a protocol using daily IV ceftriaxone with follow-up at the day treatment center (DTC) was used to avoid admission. In 2013, a new protocol was implanted and suggested the use of high dose (HD) oral cephalexin with follow-up at the DTC for those patients. The aim of this study was to evaluate the safety and efficacy of the HD cephalexin protocol to treat moderate cellulitis in children as outpatient. Methods: A retrospective chart review was conducted. Children were included if they presented to the ED between January 2014 and 2016 and were diagnosed with a moderate cellulitis sufficiently severe to request a follow up at DTC and who were treated according to the standard of care with the HD oral cephalexin (100 mg/kg/day) protocol. Descriptive statistics for clinical characteristics of patients upon presentation, as well as for treatment characteristics in the ED and DTC were analyzed. Treatment failure was defined as: need for admission at the time of DTC evaluation, change for IV treatment in DTC or return visit to the ED. Outcomes were compared to historic controls treated with IV ceftriaxone at the DTC, where admission was avoided in 80% of cases. Results: During the study period, 682 children with cellulitis were diagnosed in our ED. Of these, 117 patients were treated using the oral HD cephalexin outpatient protocol. Success rate was 89.5% (102/114); 3 patients had an alternative diagnosis at DTC. Treatment failure was reported in 12 cases; 10 patients (8.8%) required admission, one (0.9%) received IV antibiotics at DTC, and one (0.9%) had a return visit to the ED without admission or change to the treatment. This compares favorably with the previous study using IV ceftriaxone (success rate of 80%). No severe deep infections were reported or missed; 4 patients required drainage. The mean number of visits per patient required at the DTC was 1.6. Conclusion: Treatment of moderate cellulitis requiring a follow-up in a DTC, using an oral outpatient protocol with HD cephalexin is a secure and effective option. By reducing hospitalization rate and avoiding the need for painful IV insertion, HD cephalexin is a favourable option in the management of moderate cellulitis for pediatric patients, when no criteria of toxicity are present.

Dietary Supplementation with Specific Collagen Peptides Has a Body Mass Index-Dependent Beneficial Effect on Cellulite Morphology.

In this double-blind, placebo-controlled clinical study, we investigated the efficacy of specific bioactive collagen peptides (BCP) on the cellulite treatment of normal and overweight women. In total, 105 women aged 24–50 years with moderate cellulite were randomized to orally receive a daily dosage of 2.5 g BCP or a placebo over 6 months. The degree of cellulite was evaluated before starting the treatment and after 3 and 6 months of intake. In addition, skin waviness, dermal density, and the length of subcutaneous borderline were assessed. BCP treatment led to a statistically significant decrease in the degree of cellulite and a reduced skin waviness on thighs (P < 0.05) in normal weight women. Moreover, dermal density was significantly improved (P < 0.05) compared to placebo. The subcutaneous borderline showed a significant shortening after BCP intake compared to the beginning of the study, indicating cellulite improvement, but the data failed to reach statistical significance compared to placebo. The efficacy of BCP treatment was also confirmed in overweight women, although the impact was less pronounced in comparison with women of normal body weight. The results of the study demonstrated that a regular ingestion of BCP over a period of 6 months led to a clear improvement of the skin appearance in women suffering from moderate cellulite. Based on the current data, it can be concluded that a long-term therapy with orally administered BCP leads to an improvement of cellulite and has a positive impact on skin health.

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

BackgroundCellulite is a serious cosmetic concern for most of the 90% of women affected by it.ObjectiveTo assess the clinical efficacy of a complex integral anti-cellulite gel.MethodsThis 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.ResultsAt 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.ConclusionAll results validate the efficacy of the present integral formulation to significantly reduce signs of cellulite and reshape the silhouette.

Safety and Efficacy of the Treatment of Cellulite and Contour Irregularities Utilizing a Petite Handpiece with a Dual Wavelength Laser-Suction Device with Massage

Introduction: To evaluate the safety and efficacy of a petite handpiece with a low-level, dual-wavelength laser energy and massage device for the treatment of cellulite and contour irregularities. Materials and Methods: Thirteen female subjects with mild to moderate cellulite and contour irregularities were enrolled in the study. Eight treatments, delivered twice weekly, were performed with the low-level, dual-wavelength laser and massage device using a new petite handpiece. Digital photography, weight, body mass index, and circumference measurements were recorded at baseline, 1 week, 1 month, and 3 months. Patient satisfaction surveys were conducted via a 6-point numerical grading system (ranging from 1 = extremely dissatisfied to 6 = extremely satisfied) at 1 week, 1 month, and 3 months after treatment. Results: Improvement in the appearance of cellulite and circumference reduction was found to be highest in patients receiving treatment to smaller areas (arms, knees, and upper back). The patient satisfaction rating was very high, and all patients would recommend the treatment to a friend or family member. Conclusions: Low-level, dual-wavelength laser energy and massage treatment using the petite handpiece safely improves the appearance of cellulite affecting the upper back, arms, abdomen, and knees.

Double-Opposing Rotation-Advancement Flaps for Closure of Forehead Defects

To describe a local flap for closure of forehead defects of all sizes that does not alter the brow position or hairline. Retrospective review of 16 cases in which the double-opposing rotation-advancement flaps were used for closure of small (<10 cm2), medium (10-20 cm2), and large (>20 cm2) forehead defects. This technique was developed from Orticochea's method for closure of large scalp wounds. All 16 patients underwent single-stage closure of forehead defects using our design. Six patients were men, 8 were women (mean age, 71 years). Preoperative defect sizes ranged from 3 to 30 cm2 (mean, 18 cm2). All wounds resulted from Mohs surgery for cutaneous malignant neoplasms; 2 were adjacent to previous reconstructions. No recurrence of tumor was seen during the study period. No permanent frontal branch injuries occurred. One patient developed a moderate cellulitis. Photographic analysis showed that brow position and hairline contour were maintained in all cases. The double-opposing rotation-advancement flap closure is a versatile reconstructive option for small, medium, and large forehead defects. The technique involves elevation of opposing, asymmetric flaps, with subsequent rotation of one side and advancement of the contralateral side. Single-stage closure may be accomplished without unappealing changes to the brow position or hairline.

Reduction in thigh circumference and improvement in the appearance of cellulite with dual-wavelength, low-level laser energy and massage

Objectives: This study evaluated the efficacy and safety of a low-level, dual-wavelength laser energy and massage device for improving the appearance of cellulite and reducing thigh circumference. Methods: Subjects (n = 83) with mild to moderate cellulite enrolled in this IRB-approved, open-label, multicenter study. Their right or left thighs received eight treatments with a low-level, dual-wavelength laser and massage device. The untreated contralateral thigh served as a control. Circumferences of the upper, middle, and lower thighs (treated and untreated) were measured before the fifth and eighth treatments and 1 month after the final treatment. Results: Reduction in thigh circumference of the treated areas exceeded those of the control areas for the upper, middle, and lower thigh in most subjects. The maximum reduction (−0.82 cm) occurred in the upper thigh at 1 month. The mean reduction of the upper, middle, and lower thigh circumferences was −0.64 cm for the treated thighs compared to −0.20 cm for untreated thighs. The difference was significant (p < 0.0001). Fifty-nine (71.1%) treatment thighs lost circumference compared to 44 (53.0%) control thighs. Resolution of adverse effects including erythema, swelling, and increased urination was seen within 30 minutes after treatment. All were resolved without sequelae and within the expected duration. Conclusion: The low-level, dual-wavelength laser energy and massage device safely improves the appearance of cellulite while reducing thigh circumference.

Evaluation of a Noninvasive, Dual-Wavelength Laser–Suction and Massage Device for the Regional Treatment of Cellulite

Cellulite is a condition usually limited to women. The most common location for this surface irregularity is the thigh. Evaluation of treatment efficacy is difficult because of the reliance on patient satisfaction surveys and flash photography, which can "flatten" surface texture. Reproducibility of photographs is also difficult, as subtle changes in body position can affect appearance. Twenty women with mild to moderate cellulite of their lateral thighs were enrolled. Pretreatment and posttreatment assessment included patient weight, body mass index, percentage body fat, standard digital photographs, VECTRA three-dimensional images, and patient questionnaire. Patients received two treatments per week for 4 weeks. Treatment time was 15 minutes per thigh using the SmoothShapes device. Patients were evaluated 1, 3, and 6 months after their last treatment. To be considered improved after treatment, both thighs needed clear improvement in contour as determined by the "untextured" images obtained with the VECTRA camera system. This device depicts skin contour independent of incident lighting. There were no complications. Seventeen patients had complete data for analysis. Ninety-four percent of the patients felt their cellulite was improved. VECTRA analysis showed 82 percent improvement at 1 month, 76 percent improvement at 3 months, and 76 percent improvement at 6 months. Initial cellulite irregularities and improvement were more difficult to discern using standard digital photographs. There was an average increase in patient weight, body mass index, and percentage body fat at 6 months. The SmoothShapes device provided improvement in surface contour (cellulite) 6 months after the last treatment in the majority of the patients based on patient survey and VECTRA analysis.

Metacarpal bone sequestrum in a heifer: A case report

A swelling above the right metacarpal joint was noticed at suture removal, after repair of a flank wound, in a 22-month-old, pregnant, HolsteinFriesian heifer. Further examination revealed a superficial horizontal wound of approximately 6 cm in length on the latero-dorsal aspect of the limb, a smaller wound on the palmar aspect and moderate cellulitis (Fig. 1). There was no evidence of joint involvement. At the time, the heifer was housed in a straw yard with two other cattle and was being fed hay ad libitum from a ring feeder. The animal’s body weight was estimated at 490 kg, based on a weight-tape.

An Open Randomized Controlled Study on the Efficacy of Low-Sodium Water Intake Evaluated by Non-Invasive Methods in Patients with Cellulite

Cellulite is the result of complex physiological changes of the subcutaneous fat layer and of microcirculation, clinically manifesting as orange peel skin especially in women and involving thighs, buttocks, and abdomen. An adequate water intake has been suggested to be helpful in controlling the development and worsening of the disease. An open randomized controlled study has been performed to evaluate modification induced by an adequate diet associated to low-sodium or high-sodium water intake on some clinical features of patients affected with mild to moderate cellulite. Non-invasive instrumental investigations (Bioelectrical Impedance Analysis (BIA), thermography and skin echography) were used before and after dietary treatment. A significant improvement of the disease, in terms of weight loss, cutaneous microcirculation and reduction of subcutaneous fat layer, was observed in the group of patients who underwent low-sodium water intake. An adequate dietary treatment associated to a low-sodium water intake is able to efficiently controll some biological and clinical parameters of mild to moderate cellulite.

Topical retinol improves cellulite

A group of 20 women with moderate cellulite of the thighs were treated twice daily on one side for 6 months with a 0.3% stabilized retinol cream while the opposite side was treated with the vehicle, following a double-blind format. Objective measurements included ultrasound measurement of thickness using a 20 MHz B-scan, and laser Doppler velocimetry for blood flow. The panelists and a dermatologist estimated the degree of improvement on a global scale. Of 19 subjects, 13 rated the retinol side as more improved, 7 registering good effects. The dermatologist's estimates were largely congruent with those of the subjects. There was also a marked reduction in the density of hypoechogenic areas on the retinol sides, from 53% to 18% of black pixels on image analysis. Blood flow measurements were unchanged on the vehicle sides but increased significantly on the retinol sides. Thickness measurements by ultrasound scan were unchanged on the vehicle sides but increased significantly on the retinol sides, from 1.44 to 1.60 mm. Retinol may be viewed as a prodrug which the skin metabolizes to retinoic acid. The beneficial effects of retinol are consistent with previous reports of increased synthesis of glycosaminoglycans and collagen.