A randomized, placebo-controlled trial of topical retinol in the treatment of cellulite

Treatment for cellulite

Cellulite is a multifactorial condition that is present in 80% to 90% of postpubertal women and is one of the most intolerable esthetic imperfections. There are several theories on the pathophysiology of cellulite, and a number of different therapeutic regimens have been developed, from topical treatments to mechanical or energy-based devices. In this brief review, we summarize the scientific landscape to determine the clinical evidence with regard to the safety and efficacy of cellulite treatment options. Clinical protocols and the author’s experience using a combination of internal and external procedures are also discussed. Studies using laser and light modalities along with radiofrequency have shown improvements in cellulite and a good safety profile, but acoustic wave therapy, subcision, and the 1440-nm Nd:YAG minimally invasive laser have demonstrated the most beneficial results in cellulite reduction. Although there is paucity of scientific evidence for treatments that improve cellulite, future emerging options and their combination may pave the way to eradicate this primarily cosmetic esthetic concern.

Cellulite: an evidence-based review

BACKGROUND

Cellulite is a multifactorial condition that is present in 80-90 % of post-pubertal women. Despite its high prevalence, it remains a major cosmetic concern for women. A wide range of products and treatments for cellulite reduction is available; however, no systematic review has been performed so far to evaluate the efficacy of the available treatment options for cellulite.

OBJECTIVE

The objective of this review is to provide a systematic evaluation of the scientific evidence of the efficacy of treatments for cellulite reduction.

METHODS

This systematic review followed the PRISMA guidelines for reporting systematic reviews and meta-analyses. Only original articles in English or German reporting data on the efficacy of cellulite treatments from in vivo human studies were considered. In total, 67 articles were analyzed for the following information: therapy, presence of a control group, randomization, blinding, sample size, description of statistical methods, results, and level of evidence.

RESULTS

Most of the evaluated studies, including laser- and light-based modalities, radiofrequency, and others had important methodological flaws; some did not use cellulite severity as an endpoint or did not provide sufficient statistical analyses. Of the 67 studies analyzed in this review, only 19 were placebo-controlled studies with randomization. Some evidence for potential benefit was only seen for acoustic wave therapy (AWT) and the 1440 nm Nd:YAG minimally invasive laser.

CONCLUSION

This article provides a systematic evaluation of the scientific evidence of the efficacy of treatment for cellulite reduction. No clear evidence of good efficacy could be identified in any of the evaluated cellulite treatments.

Cellulite treatment: a comprehensive literature review

An effective and long-term treatment of cellulite has not been well established. To our knowledge, no review has analyzed the whole range of treatments for this condition. We conducted a review of in vivo studies on humans adopting the key words "cellulite" and "treatment." The studies were included according to eligibility criteria. We performed an analysis to estimate the overall effect of cellulite treatments from clinical studies. Medline library was screened up to December 2014 to identify eligible studies. We included 73 original studies in the present review. All of them were clinical studies, in most of them, only women were recruited. Above the studies searched up, 66 tested the effectiveness of an exclusive treatment performed without the association to other procedures: 11 topical agents, 10 shock-wave therapy, 10 radio frequency, eight laser therapy, five oral therapy, four manual massage therapy, three carbon dioxide therapy, two compressive therapy, two infrared therapy, one dermabrasion, and 11 devices that use an association of multiple treatments. Seven papers tested a combination of two or more treatments. The mean difference of clinical morphologic features and ultrastructural changes between the treated group and the controlled showed significant heterogeneity between studies. It is still difficult to indicate an exclusive and effective single treatment for this condition. Our analysis purposed to obtain a complete overview of the available treatments in cellulite reduction.

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.

Single treatment of grades II and III cellulite using a minimally invasive 1,440-nm pulsed Nd:YAG laser and side-firing fiber: an institutional review board-approved study with a 24-month follow-up period

BACKGROUND

Cellulite represents one of the common topographic alterations to the skin surface and one of the structural changes to the subdermal fat and septal band of the posterolateral thighs. Currently, no treatment exists to address this entity with a multifactorial genesis that produces long-term beneficial outcomes. This clinical study evaluated the safety and efficacy of the 1,440-nm laser and the duration of the clinical benefits during 2 years.

METHODS

Initially, 25 healthy women with thigh cellulite were enrolled in this prospective institutional review board (IRB)-approved study. For grade II cellulite, the laser fiber delivered up to 1,000 J of energy to the undersurface of the entire involved skin. For grade III cellulite, the laser fiber distributed 1,300 to 1,500 J of energy to melt the subdermal fat, subcise the taut septal bands, and heat the reticular dermis. Baseline and posttreatment analyses included standardized high-resolution photography, skin elasticity measurements, ultrasound scanning for dermal thickness, histology, investigator global assessment scores, and recording of adverse events.

RESULTS

Of the 24 subjects who underwent treatment, only 20 were available for the 6-month follow-up assessment. Objective measurements at 2 years demonstrated an increase over the baseline mean skin elasticity (34 %) and mean dermal thickness (11 %), as well as an increase in the average percentage of dermal thickening determined by ultrasound imaging. Independent investigator global assessments were rated higher for grade II subjects than for grade III subjects throughout the 2-year follow-up period. Mild adverse events disappeared by the third month.

CONCLUSIONS

This IRB-conducted clinical trial, as part of a multicenter study for Food and Drug Administration approval, demonstrated the safety and efficacy of a single minimally invasive treatment for grades II and III thigh cellulite during a 2-year follow-up period.

LEVEL OF EVIDENCE II

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 .

Efficacy of cosmetic products in cellulite reduction: systematic review and meta-analysis

BACKGROUND

The number of original articles investigating the efficacy of cosmetic products in cellulite reduction increased rapidly in the last decade; however, to our knowledge, no systematic review and meta-analysis has been performed so far.

OBJECTIVE

We conducted a systematic review of in vivo studies on humans adopting the PRISMA guidelines. Moreover, we used a meta-analytic approach to estimate the overall effect of cosmetic creams in cellulite treatment from controlled trials with more than 10 patients per arm, using thigh circumference reduction as the outcome measure.

METHODS

Medline and Embase were searched up to August 2012 to identify eligible studies.

RESULTS

Twenty-one original studies were included in the present systematic review. All studies were clinical trials, most of them recruited women only and 67% had an intra-patient study design. About half of the active cosmetic creams tested only contained one active ingredient among xanthenes, herbals or retinoids. The other studies tested cosmetic creams with more complex formulations and most of them included xanthenes. A total of seven controlled trials satisfied the inclusion criteria for the meta-analysis. The pooled mean difference of thigh circumference reduction between the treated and the controlled group was -0.46 cm (95% confidence intervals, CI: -0.85, -0.08), with significant heterogeneity between studies (P < 0.001).

CONCLUSION

This article provides a systematic evaluation of the scientific evidence of the efficacy of cosmetic products in cellulite reduction and supports a moderate efficacy in thigh circumference reduction.

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.

Cellulite: nature and aetiopathogenesis

Only a limited number of studies on cellulite have been published in the international literature and many of them reach somewhat antithetical conclusions. Consequently, it is not yet possible to reconcile the extreme differences of opinion which have lingered on for years concerning the nature of this disorder, as well as its origin and even the most basic aspects of its histopathological classification. It does not even have a recognized name: in fact, the term 'cellulitis' is used in scientific English to indicate a spreading gangrenous infection of the subcutaneous cellular tissue. The other terms used from time to time [panniculitis, lipodystrophy, edematofibrosclerotic panniculitis (EFP), liposclerosis, lipoedema, etc.] have quite different morphological and pathogenetic connotations in general. Over the last few decades, three major conflicting theories have emerged in relation to the ethiopathogenesis of cellulite. These indicate, respectively, the following causes: 1. Oedema caused by excessive hydrophilia of the intercellular matrix. 2. A homeostatic alteration on a regional microcirculatory level; this pathogenetic theory is summarized in a synthetic and self-explanatory denomination: EFP. 3. A peculiar anatomical conformation of the subcutaneous tissue of women, different from male morphology. These theories must all now be updated in the light of recent advances on the sophisticated and composite physiopathology of the adipose organ - which acts not only as a control device which regulates the systematic equilibrium of energy and modulates the food intake and the metabolism of other tissue substrate through a multiple glandular secretion of hormones and parahormones.

Commentary on cellulite: skin mechanobiology and the waist-to-hip ratio

Cellulite is a gender-related condition which is the clinical expression of conformational changes taking place in the fibrous strands partitioning the hypodermis. The affected skin areas are those where fat deposition is under the influence of estrogens. Some hypodermal fibrous strands become enlarged and others become loose and look similar to striae distensae. Cellulite is not a result of increased body mass, but its aspect may be influenced by the waist-to-hip ratio.

Cellulite: a review of its physiology and treatment

Cellulite affects 85-98% of post-pubertal females of all races. While not a pathologic condition, it remains an issue of cosmetic concern to a great number of individuals. Despite its high prevalence, there have been few scientific investigations into the physiology of cellulite. There have only been a few dozen peer-reviewed articles devoted to cellulite in the medical literature in the past 30 years. There is no definitive explanation for its presentation. This greatly complicates the ability to treat or improve it. The four leading hypotheses that purport to explain the physiology of cellulite include: sexually dimorphic skin architecture, altered connective tissue septae, vascular changes and inflammatory factors. Treatment modalities can be divided into four main categories: attenuation of aggravating factors, physical and mechanical methods, pharmacological agents and laser. There are no truly effective treatments for cellulite.

Use of intense pulsed light and a retinyl-based cream as a potential treatment for cellulite: a pilot study

BACKGROUND

There are few therapeutic treatments established for cellulite.

OBJECTIVE

We studied the response of intense pulsed light (IPL) treatment with or without a compounded prescription retinyl-based cream on a small group of patients who had visible cellulite present on the buttocks and thigh regions.

PATIENTS AND METHODS

Twenty patients were selected to complete a 12-week course of IPL treatment either with or without a retinyl-based cream. Assessment was based on visual evaluation, photographs, skin ultrasounds, and patient satisfaction.

RESULTS

Fifteen (75%) completed the study, and nine (60%) had a self-improvement rating of >or= 50%. Seven (78%) of nine patients used IPL/cream. Of the remaining six (40%) completing the study, four (27%) had self-improvement ratings of 25-50% and two (13%; IPL only) were considered treatment failures with a rating of 10-25%. Both IPL/cream and IPL-only groups exhibited an improvement in the smoothness of the affected area even following weight gain. Skin ultrasounds confirmed an increase in the deposition of collagen. During an 8-month phone follow-up, 8 (67%) of 12 responding reported the same or improved results.

CONCLUSION

IPL treatment with or without a retinyl-based cream can improve the appearance of peau d'orange cellulite, though the cream may augment cosmetic improvement. This approach is well tolerated, has minimal side effects, and is accompanied by a high degree of patient satisfaction.

Can cellulite be treated with low-energy extracorporeal shock wave therapy?

The present study investigates the effects of low-energy defocused extracorporeal generated shock waves on collagen structure of cellulite afflicted skin. Cellulite measurement using high-resolution ultrasound technology was performed before and after low-energy defocused extracorporeal shock wave therapy (ESWT) in 21 female subjects. ESWT was applied onto the skin at the lateral thigh twice a week for a period of six weeks. Results provide evidence that low-energy defocused ESWT caused remodeling of the collagen within the dermis of the tested region. Improving device-parameters and therapy regimes will be essential for future development of a scientific based approach to cellulite treatment.

[Electromagnetic lipolysis and semicircular lipoatrophy of the thighs]

INTRODUCTION

The semicircular lipoatrophy of the thighs is a disorder whose incidence remained rare for years. Only recently, an "epidemic" situation emerged, affecting hundreds of subjects who shared a status of administrative employee.

OBSERVATION

The older etiopathogenic hypotheses give way to a newer one implying the electromagnetic fields generated by computers and their wirings. The resulting modifications in the intrinsic bioelectrical properties of the skin could influence the biology of macrophages exhibiting lipophagic activity in the hypodermis. The electroactivation of these cells could lead to TNF-alpha release.

DISCUSSION

The semicircular lipoatrophy of the thighs is a problem that may affect an employee out of two. Rather than hoping an efficaceous drug therapy, prevention must be advocated by adapting the work conditions related to the use of computerized devices.

Effect of Weight Loss on Cellulite: Gynoid Lypodystrophy

BACKGROUND

Gynoid lipodystrophy (cellulite) affects most women, and many seek plastic surgery consultation to improve appearance. Various products are offered, but the literature on the cause and treatment is limited. Understanding the biological and biophysical factors that affect severity may facilitate the development of effective therapies. There has been a dramatic increase in the number of people who have lost significant weight as a result of bariatric surgery or medically supervised weight programs. The effect of weight loss on cellulite severity has not been systematically studied and remains a common patient concern. The authors hypothesized that cellulite severity would decrease with weight loss and subsequent decrease in subcutaneous fat in most subjects.

METHODS

The authors examined the cellulite changes in female subjects who were enrolled in medically supervised weight loss programs using quantitative surface roughness by three-dimensional laser surface scanning, tissue composition by dual energy x-ray absorptiometry, dermal-subcutaneous structure with three-dimensional ultrasound, and tissue elasticity with biomechanical measurements.

RESULTS

The majority of subjects had an improvement in cellulite with weight loss, but the condition worsened for others. Improvement was associated with significant reductions in weight and percentage of thigh fat, significantly higher starting body mass index, and significantly greater initial severity. Cellulite worsened with a significantly smaller starting body mass index, smaller reductions in weight accompanied by no change in percentage of thigh fat, and significant increases in tissue compliance.

CONCLUSIONS

Cellulite is a complex condition, and treatments such as weight loss have variable effects on the improvement or worsening of this condition. Additional studies are required to understand how the factors that influence and modulate cellulite severity, particularly those at the level of the subcutaneous tissue septa, can be manipulated to improve this condition.

Obesity and dermatology

Obesity is associated with a number of dermatoses. It affects cutaneous sensation, temperature regulation, foot shape, and vasculature. Acanthosis nigricans is the most common dermatological manifestation of obesity. Skin tags are more commonly associated with diabetes than with obesity. Obesity increases the incidence of cutaneous infections that include: candidiasis, intertigo, candida folliculitis, furunculosis, erythrasma, tinea cruris, and folliculitis. Less common infections include cellulitis, necrotizing fasciitis, and gas gangrene. Leg ulcerations, lymphedema, plantar hyperkeratosis, and striae are more common with obesity. Hormonal abnormalities and genetic syndromes (Prader-Willi) are related to obesity and its dermatoses; however, cellulite is not related to obesity.