Cellulite: A Review of Causes and Treatments

Cellulite: A Review of Causes and Treatments

Cellulite can affect as many as 98% of females at some stage after they hit puberty. Whilst it isn’t an illness and doesn’t have any associated morbidity, it is still something that have a negative effect on quality of life and confidence.

There are a number of home remedies, old wives tales and anecdotes about the best ways to improve the dimpled look of cellulite, but very few with clinical evidence. Many local beauty salons promise to achieve this with their latest ‘on trend’ products, creams and gadgets but often fall short.

In this article I’ll review the current studies and information on cellulite – this will be an honest look at what the research says. Its not an exhaustive look at all treatments, just the most popular in the literature.

What is Cellulite?

The name ‘cellulite’ has its origins in French medical literature. It is characterized by a dimpling of the skin and likened to the appearance of orange peel or cottage cheese. It is otherwise known as adiposis edematosa, dermopanniculosis deformans status protrusus cutis, and gynoid lipodystrophy

It is not an illness in the true sense – it has no attached morbidity or mortality to it, but is a concern to the many women that suffer from it. In fact, this condition affects 85–98% of postpubertal females of all races [1]. It is commonly seen in the thigh and buttocks of females and is rarely seen in males unless they have an underlying androgen deficiency.

Image result for cellulite dermis

What Causes Cellulite?

Underneath the outermost layer of the skin – referred to as the epidermis – lies the dermis. Just beneath this lie a number of different structures including blood vessels, nerves, sweat glands and hair follicles. Finally, underneath this is the areolar layer.

Within this areolar layer are a number of fat cells, surrounded by a mesh of connective tissue made from collagen, elastic tissue, and reticular fibers. It’s purpose is to bind the skin to the muscle that lies beneath it, so it has to be fairly loose to allow articulation and general movement the fact that it is loose may be problematic as it leaves space in and around it for fat cells to collect.

There are a number of theories about the cause of cellulite. The most commonly accepted hypothesis is that as the fat cells under the areolar layer are arranged vertically, this structural formation may lead to some fat cells escaping into the dermal layer. When this occurs, the protruding fat cells cause a bumpy appearance under the skin, which we commonly refer to as cellulite.

Vascular changes, inflammatory factors, chronic venous insufficiency, localized edema due to leaking of fluid and proteins into the dermis, and functional defects in lymphatic drainage  have all been proposed to lead to fat accumulation. 

If you think about the organisation of the areolar layer in females, it is structured into compartments  which unfortunately favors the escape of fat cells into the dermis. Conversely, in males the areolar layer in structured in a criss-cross shape which ‘imprisons’ fat cells. These cells can still increase in size, but tend to expand laterally and remain internalized. Additionally, males tend to have a more robust, stronger dermal and epidermal tissue layers that aid in protection from any potential fat cell protrusion [2].

Image result for areolar layer men and women cellulite

Can You Improve Cellulite?

The prevalence of cellulite has led to many attempts at treatment, including a variety of topical solutions, massage-based therapies, and surgical techniques—most with sub-optimal clinical effects [3]

The majority of reported benefits are anecdotal, and therefore unfortunately are difficult to assess. Many of the ‘scientific studies’ used to sell products use qualitative research methods – i.e. questionnaires, which can be subjective. Many of these are funded by the companies that are selling the products in testing, so unsurprisingly they always tend to squeeze positive comments out of study volunteers – many women that participate in these studies are offered free gifts so participate which may ‘sway’ the feedback they provide. I’m not looking at these type of studies as they are meaningless.

Secondary confounding factors, such as coincidental changes to diet and exercise make any scientific conclusions difficult, as does the fact that there is no standard criteria to assess changes to cellulite. Common measurements used are ‘before and after’ photography, as well as thigh circumferences – these are very far from perfect. The most robust is probably MRI.



This has been a common treatment for cellulite for many years. It is a way of thinning the superficial areolar layer of fat via high frequency vibrations, suction and drainage. Some review studies have found promising results across a wide range of ages and skin qualities [4], but others have reported that the dimpling effect increased after the procedure [5, 6].

The largest review to date [1] does not recommend liposuction as an effective treatment for cellulite.


As a mechanical treatment, massage can have a temporary beneficial effect as it improves blood flow to and from the affected areas. One study found that deep massage induced alterations to dermis connective tissue via internal and external mechanical loading [7]. This was echoed in another study which suggested that not only does massage improve blood flow it is also likely to improve  cellular level collagen quality as well [8].

However, another study using Endermologie – a suction massage technique developed in France – found that when volunteers reported improvements to their cellulite via self-evaluation, benefits could only be attributed to weight loss secondary to diet and exercise, not the therapy itself [9].

Massage appears to be effective in short-term benefits to blood flow and excess fluid accumulation and may potentially offer some longer-term benefits although current evidence is limited.

Topical Ointments and Creams

The use of retinol, lactic acid, caffeine and herbals amongst many others are another popular method of treatment. They are also possibly the widest used and most available treatment too.  Spas, boutiques and the internet are full of various topical ointments that offer miracle cures [10] but surprisingly, there is actually a limited amount of high-quality studies to draw upon to evaluate their effectiveness.

Two of the most tested compounds are aminophylline and retinol. Aminophylline has been reported to stimulate lipolysis – the breakdown of fat cells. It has also been used in treatments for asthma and also as a diuretic. A study published in Plastic & Reconstructive Surgery [9] reported no significant difference in a group of women, concluding that the treatment was ineffective. Only 3 out of 10 of them women reported any positive changes. A review by Wanner et al [11] found that the treatment reduced thigh circumference slightly, but had no effect of cellulite appearance.

Retinol ointments are a well-known ‘anti-ageing’ ingredient in face creams. Otherwise known as vitamin A, this treatment is used to increase dermis thickness. Some studies have reported self-evaluated improvements with long-term use  [12] . Other studies have reported no differences over similar time frames [13].

Creams seem to be largely ineffective and some struggle to permeate the skin meaning that they simply can’t penetrate the dermal layer.


“The next frontier in the treatment of cellulite may be lasers” [1]

Whilst probably overselling it somewhat, this method of treatment is the newest and potentially most effective treatment on offer. The laser produces a thermal effect using light heat on organic tissue and is currently used for various dermatological applications including body composition and even muscle size. It is thought that the heat may cause the areolar layer to improve in structural integrity and therefore ‘tighten up’.

Research is unfortunately limited at this point, but the studies that are available are promising. One paper found that 6 treatments using a radio-frequency device caused positive histologic changes suggesting skin tightening as the method of improvement [14]. Similar results have been found in other studies too [15, 16].

As research on this method is in its early stages, it is difficult to assess whether or not it can continue to appear beneficial. It is also not possible to predict any long-term side effects and potential adverse reactions. This may be a treatment to approach with caution until more research has been released. It is promising, but greatly understudied.



Frustratingly there seems to be a lack of studies and general consensus regarding effective cellulite treatments. At present it is hard to recommend one particular method due to lack of clear research findings. Some appear to have more potential than others but ultimately it is very much on a ‘study by study’ basis. The use of lasers seems to have potential although may be understudied at this stage.

It is important, as with any aspect of lifestyle, that a well-balanced diet and physical activity program be undertaken to improve overall body composition. Alongside that you may wish to try some of the treatments discussed above just to see if it works for you – but be aware that as much as these products are sold with promises, it just might not work for you.


  1. Avram, M. Cellulite: a review of its physiology and treatment. J Cosmet Laser Ther. 2005; 7: 1–5
  2. Wanner, M., and Avram, M. An evidence-based assessment of treatments for cellulite. Journal of Drugs in Dermatology, 2008; 7(4): 341-345
  3. Alster, T et al. Cellulite treatment using a novel combination radiofrequency, infrared light, and mechanical tissue manipulation device. Journal of Cosmetic and Laser Therapy. 2005; 7: 81–85
  4. Gasparotti M. Superficial liposuction: a new application of the technique for aged and flaccid skin. Aesthet Plas Surg. 1992; 16: 141–53
  5. Coleman WP, Hanke CW, Alt TH, et al. Liposuction Cosmetic Surgery of the Skin: Principles and Practice. BC Decker Inc: Philadelphia, PA, 1991: 213–38
  6. Van Vliet, M., Ortiz, A., Avram, M.M, and Yamauchi, P.S. An assessment of traditional and novel therapies for cellulite. Journal of Cosmetic and Laser Therapy, 2005; 7: 7-10
  7. Silver, F.H, Siperko, L.M., and Seehra G.P. Mechanobiology of force transduction in dermal tissue. Skin Research Technology, 2003; 9(1): 3-23
  8. Rawlings, AV. Cellulite and its treatments. International Journal of Cosmetic Science, 2006, 28, 175–190
  9. Collis N, Elliot LA, Sharpe C, Sharpe DT. Cellulite treatment: a myth or reality: a prospective randomized, controlled trial of two therapies, endermologie and aminophylline cream. Plast Reconstr Surg 1999; 104: 1110-14
  10. Hu W, Siegfried EC, Siegel DM. Product-related emphasis of skin disease information online. Arch Dermatol 2002; 138: 775–80
  11. Wanner, M., and Avram, M. An evidence-based assessment of treatments for cellulite. Journal of Drugs in Dermatology, 7(4), 341-345. 2008
  12. Kligman AM, Pagnoni AStoudemeyer. Topical retinol improves cellulite. J Dermatol Treat 1999; 10: 119–25
  13. Pierard-Franchimont, C., Pierard, G.E., Henry, F., Vroome, V., and Cauwenbergh, G. A randomized, placebo-controlled trial of topical retinol in the treatment of cellulite. American Journal of Clinical Dermatology, 2000; 1(6): 369-374
  14. Goldberg,D et al. Clinical, Laboratory, and MRI Analysis of Cellulite Treatment with a Unipolar Radiofrequency Device. Dermatologic Surgery; 34(2): 204-9
  15. del Pino, E., Rosado, R., Auela, A., Guzman, G., Arguelles, D., Rodriguez, C., and Rosado, G. M. Effect of controlled volumetric tissue heating with radiofrequency on cellulite and the subcutaneous tissue of the buttocks and thighs. Journal of Drugs in Dermatology. 2006; 5(8), 709-717
  16. Boisnic, S et al.

    Clinical and histopathological study of the TriPollar home-use device for body treatments. European journal of dermatology: EJD 20(3):367-72