Cellulite Etiology and Purported Treatment ZOE DIANA DRAELOS, MD KENNETH D. MARENUS, PHD Author's Note: This article represents a combination of knowledge from the skin care industry (Dr. Marenus) and the dermatologic ‘community (Dr. Draelos). The first of the two-part article discusses ‘current understanding of the etiology of cellulite while the second part presents purported treatments, Cellulite is a condition affecting 85% of postadolescent women characterized by dimpled tissue on the upper outer thighs, posterior upper thighs, and lower buttocks. A better understanding of the etiology of cellulite kas been obtained through ultrasonic analysis of the upper thigh and buttock tissue demonstrating herniation of the Part 1: Cellulite Etiology KENNETH D. MARENUS, PuD Cellulite Basics That is cellulite? Is it a disease or normal ex- pression of secondary sexual development? The term “cellulite” refers to the popular de- scription of the uneven, bumpy, “orange peel,” or “cot- tage cheese” appearance of the thighs, buttocks, and breasts of postpubertal women. Known medical facts regarding cellulite are as follows. Cellulite rarely ap- pears in males. Cellulite does not appear in prepubertal females. Cellulite varies in degree from mild to severe (Figure 1), and basic cellulite is not particularly related to obesity but excess weight accentuates the condition.? Cellulite reflects a variety of conditions described in the medical literature as adiposis edematosa, dermo- panniculosis deformans, status protrusus cutis, and several others.” Thus, there are several conditions that give rise to skin with the “cellulite” appearance. This illustrates that the basic definitions concerning cellulite need clarification. The etiology of cellulite can be evaluated by follow- ing structural changes in the dermis and subcutaneous fat in effected and noneffected regions. The changes in dermal structure in cellulite-affected areas are quite ap- parent. There are projections of subcutaneous fat into From the Department of Dermatology (ZDD), Bowman Gray Schoo! of Medicine, Wake Forest University, Winston-Salem, North Carolina: and Biological Research Department (KDM), Estee Lauder, Metvle, New York. Adres correspondence and reprint requests to Zoe Diana Draelos, MD, A, 624 Quaker Lane, Suite 114B, High Point, NC 27262 subcutaneous fat into the dermis. The initial changes teading to cellulite formation appear to be deterioration of the dermal matrix and oasculature, particularly loss ofthe capillary networks, lading to excess fluid retention within the dermal and subcutaneous tis- sues. This loss of the capillary network is thought to be due 10 engorged fat cells clumping together and inhibiting venous return ‘A variety of treatments, 10 include xanthines, herbal derivatives, heating, massage, and skin kneading, have been put forth as possibly reducing the dimpled skin appearance. © 1997 by the American Society for Dermatologic Surgery, Inc. Dermatol Surg. 1997;23: 177-1181, the reticular and papillary dermis. These projections are readily observed via ultrasound as low density regions among the denser dermal tissues. An increase in der- ‘mal glycosaminoglycans has been reported in cellulite effected areas.* This suggests greater water binding in these regions and manifests as low density (dark re- gions) in ultrasound images. In comparison, non-cellulite-affected areas show normal dermal structure with a mass of uniform den- sity reflecting even distribution of structural proteins and glycosaminoglycans (Figure 2). In trying to determine the etiology of cellulite, it is, possible that the gaps in dermal structure are the con- sequence of subclinical inflammatory processes that can result in the constant activation of proteinases, such as collagenase and elastase.> The activation of these en- zymes is a normal part of the inflammatory response in, order to allow for the efficient migration of immune cells to the site of activity. In this case, the stimulation of inflammatory activity may be caused by the subcutane- ous fatty tissue. Activity within the subcutaneous tissues plays an obvious role in the generation of cellulite. It is unclear if the condition results from adipocyte hypertrophy or adipolysis.®° Inflammatory cells have been observed in close proximity to the adipocytes.” The impact of in- flammation upon the adipocytes and their fat stores in these particular anatomical regions remains to be deter- mined. © 1997 by the American Society for Dermatologic Surgery, Inc. + Published by Elsevier Science Inc. u7 +1076-0512/97/817.00 + PI] $107%-0512(97)00384-4This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.