CELLULITIS

Obesity or cellulitis: Aetiology of cellulitis, Diagnosing cellulitis, Classification, Treatment.

OBESITY OR CELLULITIS?

We mistakenly use the word “cellulitis” to refer, in general, to certain obesities or adiposities located in specific areas of the body. The term is, however, inaccurate, given the fact that the clinical entity that we are referring to does not implicitly carry with it the existence of any inflammatory process.

Numerous other terms have been put forward to define this entity, but in my opinion, given its anamato-pathological characteristics, the definition given by S. Curri, “vasculopathic dermopaniculosis”, is the most accurate, while the one proposed by Bartoletti, “fibroedematosclerotic paniculopathy”, is also acceptable. Both definitions can be accepted as correct, given that they both allude to the fatty component, to the vascular component (essential in the genesis of the pathology as we will see below) and to the fibrous and oedematous component that characterise the cellulitic tissue that has already formed.

BUT. . . WHAT IS IT?

Clinically speaking, it is easy to identify a cellulitic area in our body, given that a series of perfectly identifiable pointers and characteristics coincide, such as the changes that happen to the superficial subcutaneous tissue where the disease lies:

Increase of its thickness

Increase of its consistency

Increase of its sensitivity

Reduction in the mobility and the capacity to move of the different layers of skin as a result of its adherence to deeper cutaneous layers.

Touching of subcutaneous “granules” that correspond to the micronodules and macronodules that so characterise cellulitis.

All of these anomalies go to make up the well-known “orange skin” phenomenon that aesthetically defines the appearance of this disease in the affected area.

HOW DOES THIS COME ABOUT?

There is practically unanimous agreement among specialists with respect to the distinguishing of five phases associated with the formation of cellulitic tissue, or more to the point, the stages at which the destructuring of the subcutaneous tissue occurs, which will lead to the formation of the cellulitis.

1st Phase: There is no clinical manifestation, thus it is practically impossible to diagnose. This phase is characterised by a slowing down of lymphatic and venous microcirculation. The vessels dilate and the blood stays in them longer than normal.

2nd Phase: Due to the persistence of the blood stasis, and of the vasodilatation, the wall of the small venous and lymphatic vessels becomes more porous allowing the liquid to reach the exterior. This is what is known as the edematisation of the connective tissue. This liquid is very rich in electrolytes (basically sodium) and in mucopolysaccharides.

3rd Phase: This inundation brings with it a series of chemical reactions, given the fact that these foreign substances create a pressure problem on taking up an inappropriate space, making the correct nutrition of the fatty cells that are located in the surrounding area even more difficult. This phenomenon is known as the hyperpolymerisation of the mucopolysaccharides, where we witness a transformation of the serous liquid into a thicker gel-like substance, which impedes the interchanges between the vessels and the adipose cells even more. These cells, on being unable to offload their metabolites into the microcirculatory stream, become considerably enlarged, to the extent that they may even break and spill their fatty and toxic content to the exterior.

4th Phase: Over the course of a few months a fibrous proliferation occurs in which the fibrous substance of the dermis and the hypoderm arranges itself into swollen, turgid and translucent fibrils forming genuine networks that cover all the elements: fatty cells, nerve, venous and lymphatic vessels, making the nutritional interchanges between the vessels and the cells even more difficult. The compression of the nerve endings will be painful, and the compression of the adipocytes gives rise to the padded appearance typical of the cellulitic phenomenon.

5th Phase: The evolution of the previous phase becomes a genuine cicatricial fibrosis or sclerosis which compresses the cells, lymphatic and nerve vessels and arranges itself into micronodules, which on joining together, form macronodules which we can sometimes touch in the cellulitic areas. Part of these meshes pull from the bottom layers of the skin forming those characteristic undulations that we call orange skin.

The real problem is that, as we have seen, a vicious circle arises in which, if the beginning of the whole problem was a vascular stasis that inhibited the proper nutrition of the cells, it ends up in the compression of these same vessels, which only serves to make the nutritional problem even worse.

The immediate result of this approach is personal, and I fee that we all understand it as fairly correct. I do not see how aggressive and radical anti-cellulitic treatments can be proposed which only act on the fatty component, when it has been comprehensively shown that the genesis of the cellulitis problem is a microcirculatory disorder.

AETIOLOGY: WHY DOES IT HAPPEN?

Cellulitis is a multifactorial process. There is seldom a single reason that we may point to as being wholly responsible for its appearance. We know and we can specify a series of predispositional factors which are statistically linked to its presence:

Endocrinal factor: It seems quite obvious that there is a relationship between the appearance of cellulitis and the hormonal fluctuations to which the female is subject throughout her development. Firstly, because it is extremely significant that the pathology appears at the same time as the physiological hormonal changes experienced by women (puberty, pregnancy, the postnatal period, the taking of contraceptives, or menopause). Secondly, because there are numerous hormonal studies which serve to certify that both estrogens, as well as progesterone (both typically female hormones) exercise a direct effect on the fatty tissue, given that they are responsible for the increase in the volume of the adipocytes in specific areas of the woman’s body, especially in the peritrochanteric areas.

Enzymatic factors: The lipoprotein lipases, triglyceride lipases, the adenyl ciclases and cyclic-AMP, are enzymatic systems the alterations of which affect the lipolytic capacity and also affect the transformation capacity of the tryglicerides into fatty acids and glycerol by the adipocytes. These are systems which we know to be, to a greater or lesser extent, altered in the fatty tissue of patients that suffer from cellulitis.

Psychosomatic factors: Patients with neurovegetative dystonia, in which anxiety, stress, emotive phenomena etc. are especially prevalent. They possess greater lability in the metabolism and operation of their catecholamine hormones (adrenaline and noradrenaline) giving rise to hyperactive phenomena of their vasomotricity, which means that they are much more prone to suffer from cellulitis.

Genetic factors: The existence of “obese families” and “families of cellulitis sufferers” has been statistically proven. A family history of obesity and cellulitis is a predispositional factor of the first order with respect to the possibility of suffering from the same. As far as my personal casuistry is concerned, I wish to highlight the great frequency of mothers with circulatory problems, mainly of a varicose nature in my patients with cellulitis, which only goes to prove that the circulatory pathology is of prime importance in the genesis of the cellulitis problem.

Dietetic factors: There is no question whatsoever that a relationship exists between overfeeding and obesity. Notwithstanding, when linking the diet to cellulitis we must focus more on the food itself than on its quantity. Basically, we can relate the toxic – dietetic habits with the appearance of cellulitis: tobacco, alcohol, junk food, abuse of hot and heavily spiced foods etc. And of course, the consequences of an imbalanced diet, hyperuricemia, hypercholesterolemia, tendency to constipation, bad life hygiene, etc.

Mechanical factors: There is a clear link in the appearance of cellulitis in patients that suffer from orthostatic disorders, mainly flat feet, mechanical problems in the knee, spinal disorders (lumbar hyperlordosis) etc. Furthermore, we can also include in this section the mechanical compressions on the vascular terrain caused by the use of overly tight fitting clothes, and of course the statism proper to some professions (shop assistants, waitresses, etc.) who must remain for long periods of time without moving.

Vascular factors: These are fundamental factors in the disease. I would even go as far as saying that they are essential factors in the appearance of cellulitis. In fact, as we have already commented above, there is no cellulitis without a microcirculatory alteration component. Quite frequently, patients affected by cellulitis present vascular symptoms, mainly of venous return: pain, a bloated feeling in the stomach, drowsiness, varicosities and varicula in the legs etc.

DIAGNOSING CELLULITIS

Diagnosing cellulitis is not a complicated matter. Basically, if we focus on the appearance of the skin, touch it correctly and gently pinch it we will be able to confirm or not, as the case may be, the presence of cellulitic plates. The skin presents a series of irregularities, such as depressions that constitute the classic “orange skin” phenomenon. While we superficially touch the affected area we will notice the presence of irregularities such as “rice grains”, and in more advanced phases larger and more compact cellulitic nodules. The sliding capacity of the layers of skin is greatly reduced, and we feel pain when it is pinched, not to mention the fact that we cannot release it from the deeper layers. Furthermore, the skin will have a dry, cold and hardened or edematised appearance.

We normally find a series of associated signs, generally of a vascular nature, such as: cramps, sluggishness in the legs, the edematisation of the ankles, cold feet, with the skin turning a shade of pink, marble-like, and very often it is linked to the presence of varicula, varices, very frequent hematomas etc.

There are extremely sophisticated techniques such as contact Thermography which enables us to diagnose, in an objective manner, the affected areas, and which draws up a kind of map of the cellulitic region. This technique is based on the difference in heat emitted by the skin in healthy areas (warmer) with respect to the affected areas, which as a result of not being so well irrigated are colder. Thermography is seldom used in daily clinical practice.
Other techniques, such as echography or vascular exploration by means of the doppler, plethysmography or capillarioscopy, are not used very often. In truth, they only serve to show us the condition of the vascularisation of the lower members.

CLASSIFICATION OF THE CELLULITIS

The most frequently used classification is that which refers to the clinical characteristics of the cellulitis. According to Bartoletti, it can be classified as follows:

Bland Cellulitis: This normally occurs in people of a certain age. These people tend not to do any physical exercise, or have been subject to frequent and drastic slimming treatments. Muscular flabbiness is as important as the cellulitis itself.

Compact Cellulitis: This type of cellulitis is generally found in obese young people, or linked to those suffering from overweight. The cellulitis is hard and gives a sensation of tension when touched. It is the one that best responds to treatment.

Oedematous Cellulitis: This is the most frequent form of cellulitis. It is accompanied by an extremely deficient vascular condition and a general edematisation of both extremities. The vascular symptoms associated with the disease are extremely intense. It responds quite well whenever a proper treatment dealing with the return circulation is applied.

TREATMENT

Given the fact that we are tackling such a “fashionable” problem, we must bear in mind that numerous treatments have been put forward, many of which have been defined in their publicity as “definitive”. I would, however, add the epithet “deceptive” to the latter, in the light of the fact that a proper treatment of cellulitis must begin with impressing on the patient that cellulitis is a chronic disease, and that even though we might be able to cure it momentarily, it will always tend to resurface. We must further impress on the patient that the most important feature of the treatment is constancy and perseverance, that it can genuinely be cured and that we have a large storehouse of treatments to tackle the disease, and the greater amount of arms used the tackle it, the better the result will be. Nevertheless, we must bear in mind that the “maintenance” doses or treatments are as important, if not even more so, that the ones used to overcome the disease in the first instance.

On the basis of this essential premise of “correctly understanding” the cellulitic problem, we will attempt to propose the clearest and most concise therapeutic arsenal to combat it. As I have stated above, the more arms we use, the better the results we obtain will be.

HYGIENIC – DIETETIC MEASURES:

1. FOOD: In the numerous cases in which the cellulitis is linked to obesity or overweight, we must invariably draw up a diet in order to lose weight (we will deal with this in the following chapter). If this is not the case, we must propose the “healthiest” of possible diets, well balanced, with plenty of fruit and vegetables to ensure a sufficient intake of vitamins and minerals for the body. We will do our best to make the diet rich in proteins, and will try to decrease the hydrate content. Of course, such a diet must be poor in fats. We will try to keep meal rhythms as ordered as possible, always eating at regular times, without skipping any, and without any “sweet” snacks, with neither chocolates nor sweets being eaten between hours. Salt will be used in great moderation, not to mention the fact that we will also avoid hot or strong condiments and spices, as well as any OVER indulgence in sauces, mustards, etc. It is extremely important to maintain an appropriate water balance, thus we always advise our patients to imbibe a minimum of a litre and a half of water a day, and if possible not to concentrate the intake during meal times, but rather to space it out throughout the course of the day.

2. PEACE AND RELAXATION: I am well aware that this measure seems a little unusual, given the fact that we all wish to flee from the stress of daily life, but we know that insomnia, nerves, irritability and anxiety are factors that favour the appearance of cellulitis. We can advise our patients to do relaxation exercises, yoga etc. I myself, especially in cases where I feel particularly concerned about a patient’s level of anxiety, stress, difficulty in getting to sleep, tendency to depression, extremely low spirits etc., resort to a product with a hyperic extract base, which has been proved to be the preferred plant in the treatment of cases of slight psycho-emotional imbalances. The medicine is question is called DISTONICUM, and I recommend that two capsules be taken twice daily, at breakfast and another dose at dinner time. After a fortnight I assess how the patient is feeling, and normally reduce the dose to only two capsules at breakfast.

3. PHYSICAL EXERCISE: This by no means implies advising our patients to embark on an Olympic preparation program, but merely to do some light, and above all, continuous exercise (maintenance exercises, light aerobics, cycling, swimming etc.). We are not seeking to lose weight, we simply wish to obtain good muscular toning, which will prove to be of great help, especially to those patients who are suffering from flabby cellulitis and those who have venous return problems. Whatever the case, we all agree that exercise done both moderately and constantly is the best advice we can give to everyone, given that it is the most effective way of achieving the body’s physical and emotional balance.

4. PHYSIOTHERAPY: There are several techniques that we normally use as a complement to the cellulitis treatment. They can be used either independently or in combination. They are all useful if employed by authentic professionals and are of great help in the overall context of cellulitis treatment. We list them below and provide a short commentary on their usefulness:

He – Ne LASER: This is mainly used for its normalising effects on the microcirculation; what is more, it favours lymphatic draining by decreasing the oedema, has fibrinolytic effects and decreases the painful sensation in, and rigidity of, the skin. We can use it as a preliminary measure to the application of anti-cellulitic topical products, given that we will achieve a greater penetration of their active principles.

ULTRASOUNDS: We use 3 MHz frequency ultrasounds that act at a skin depth of 2 cm. – 3 cm. It has very interesting effects which can be resumed as follows: Oedema re-absorption, analgesic, increase in the elasticity and permeability of the skin, which enables the penetration of the topical products, microcirculation stimulation, increase in local metabolism and a fibrinolytic effect. All of the aforementioned are of great use in the treatment of cellulitis, particularly compact cellulitis.

Ultrasounds must not be used on certain areas of our body: eyes, ears, ovaries or testicles, and is strictly contra-indicated on the abdomen of pregnant women, patients with pacemakers, infected and neoplastic areas. Neither will we use it on patients that have metal prostheses, nor on those areas which have recently suffered a haemorrhage.

EXCITATORY CURRENTS: These are low frequency variable current apparatus. The currents are transmitted in the form of pulse trains. They have the power to provoke muscular contractions, and are used for this purpose in order to achieve two important effects, on the one hand to increase muscular tone, an important therapy as regards flabby cellulitis, and to act on the venous and lymphatic circulation to increase their return capacity, an important effect in the general treatment of the cellulitic problem.

Their use is contra-indicated in pregnant women, people with pacemakers, on any type of muscular injury and, very importantly, on the abdomen of patients that have an intrauterine device, given that it could move the same and give rise to endometrial injuries. They are also contra-indicated in patients with phlebitis, thrombophlebitis and those who have recently suffered from an embolism.

PRESSOTHERAPY: This is a treatment which is frequently used in the drainage and resolution of oedemas. It basically consists of putting one’s legs into pneumatic boots. These are compartmentalised, and by means of a compressor they are gradually inflated from bottom to top, that is to say, upwards. They provoke tremendous circulatory activation giving rise to extremely positive effects in lymphatic problems, in the re-absorption of oedemas and in oedematous cellulitis. On the other hand, it is one of the treatments most appreciated by our patients, given that it provokes a wonderfully relaxing and restful effect in the legs.

Its use is contra-indicated against infectious processes, neoplasia, thrombosis, heart and kidney failure, as well as in cases of patients who suffer from severe blood pressure problems.

MANUAL LYMPHATIC DRAINAGE: This technique is carried out by means of a completely atraumatic massage, the purpose of which is to help the return of the lymph to its collector centres. This draining of the lymphatic canals, along with its anti-oedematous effect, reduces the tendency to fibrosis and facilitates the expulsion of toxic materials that have been retained in the cellulitic areas. The contraindications associated with this technique are as follows: acute infections, neoplasia and thrombosis.

5. PHYTOTHERAPY: Modern phytotherapy has left behind that idea of an empirical science solely based on ancestral knowledge, passed on orally from generation to generation and from master to student, which purported to solve patients’ problems merely on the basis of the knowledge that “a certain plant is good for a particular pathology”. At present, the active principles of many plants are subject to scrupulous analyses. The qualitative and quantitative analyses of the same, which enable us to regulate their dosage and their intimate operative mechanism, along with extraction and manufacturing systems subject to the most rigorous methods of control mean that we are truly dealing with a “new” science, comparable to conventional Pharmacology, and on many occasions an alternative to the same, with the added advantage that it does not present the possible side-effects that are generally associated with classic medicines.

Hereinafter, whenever I wish to refer to the active principles of phytocompounds or phytocompound products, I will allow myself the luxury of providing the commercial names of all of them, given that I wish to refer, at all times, to treatments of which I have personal experience, and with which I have always managed to obtain the best results. I will always proffer the name of two or more products from different laboratories in order to avoid, with the aim in mind of always using the same active principles that I use, the reader falling into the error of different or incomplete formulations.

I always resort to Phytotherapy as the means of getting to the heart of the cellulitic problem, given that it affords me some truly extraordinary decisive effects: lymphokinetic and fibrinolytic effects, microcirculatory and anti-oedematous protectors, which I consider to be essential to embarking on a comprehensive treatment of cellulitis. I systematically include products such as BHIOERBA – 3 – LD in my treatments, given that they provide, in their composition, all of the phytotherapuetic elements that act in solving the cellulitic problem (stasis, lymphedema, microcirculatory alteration, fibrin networks, etc.).

If the cellulitis coincides with a serious venous return problem, we must tackle the same with the means that Phytotherapy provides us with. We know that Ruscus, Hamamelis, Bilberry, Sweetclover, Rutin, Buckeye, Ginkgo-Biloba extracts etc. act on capillary permeability, increasing the tone of the vascular wall and reactivating the venous return. Basically, I use VACIRTON, given that it unites all the active principles that we know as venous circulation activators, carrying out on the one hand, decisive work on the clinical problem (tired, heavy legs, painful varices, cramps etc.) and on the other hand, operating as a preventative agent with respect to the inexorable evolution that comes with the varicose pathology.

We quite often come across problems of constipation linked to cellulitic pathology. Most likely dietetic adjustment will solve the problem. However, if this is not the case, we will be obliged to resort to products rich in natural fibre, which will help us to solve the problem, thus avoiding any possible side effects. ADELPLUS, METABOL, etc. taken with plenty of water several times a day will correct the bowel movement problem, and will provide the intestine with the benefits to be had from the fibre, in addition to its carminative and reductant effects on the abdominal inflammation arising from the accumulation of gases and heavy digestions. If we need a more intensive laxative effect, I recommend the taking of a powder such as LINOFORCE with plenty of water. This will likely as not solve our problem.

Frequently, on analysing the causal factors of the cellulitis, we find ourselves with a large alimentary toxic component, implying the need to act first on the dyspeptic problem, and to assure ourselves of good hepatic – biliary functioning, and a general “detoxication” of the body as a preliminary measure to treating the cellulitis. Phytotherapy with products such as BHIOERBA – 1 - HB with a base of choleretic, cholagogic and bitter active principles, provides us with solutions and ensures us a correct hepatic functioning, essential to the proper detoxicating operations in our body.

6. TOPICAL TREATMENTS: A classic question asked by my patients refers to whether or not anti-cellulitic creams work. The answer is always the same: we cannot embark on an anti-cellulitic treatment based solely on the application of a topical use product. Even less so, if we are trying to solve a chronic problem such as cellulitis with the application of a cream one month before the beginning of summer. However, it is also true that topical use products based on logical formulations, which will act as local lipolytic agents, anti-oedematous agents, re-structuring agents of the damaged conjunctive tissue, lymphokinetic agents, vascular protector and activators of the microcirculation, if we use them continually and constantly, play no small part in treating cellulitis. Indeed, in the majority of cases they represent an essential complement to the general therapy to be applied.

VACIRTON – ANTI-CELLULITIC GEL is a phytocompound with a base of Ivy, Fucus, Tepezcohuite, Asiatic Spark, Buckeye, Cypress, Caffeine, Hamamelis etc. perfectly meets the requirements to act on all of the physiopathological components that cause cellulitis, and in addition serves to improve the appearance and texture of the skin. It must be applied smoothly and constantly. It has no side effects and I always recommend it as a complement to all the other actions that we are proposing to combat the cellulitic phenomenon.

7. MESOTHERAPY: This is the technique that is most employed to treat cellulitis. It consists of the administration of small doses of medication by means of intradermal - superficial puncturing in the area that we wish to treat. It enables us to carry out a treatment exclusively focused on the affected area, thus avoiding interfering with the rest of the body. There are strict rules to be observed, both with respect to the technique to be used, as well as regards the medicines to be injected, which must fulfil certain essential conditions in order to permit their use according to this mode of administration. Indeed, the only problems that we know of that have been caused by the Mesotherapy technique are as a result of not having complied with the standards of use required. Currently, these homeopathic medicines that have practically overthrown conventional drugs in the treatment of cellulitis. On the one hand that comply with all of the criteria to be used as mesotherapeutic agents, on the other hand then enable us to tackle all of the etiopathogenic causes of cellulitis, and on the other hand they are completely harmless, and do not present any unpleasant side effects. Personally, I systematically use a homeopathic compound called LIPODISTROFIN which has a base of Placenta – suis, Vena and Arteria-suis, Funiculus Umbilicalis, Vipera berus, Juglans, Levothyroxine, Secale, Tabacum, Fumaria, Barium carbonicum, Sepia, Aesculus and Pulsatilla. This homeopathic complex acts, above all, on al of the factors responsible for the genesis of the cellulitic process: microcirculatory, endocrinal, toxic, neurovegetative etc. If, in addition, I am of the opinion that I should act with a lipolytic effect, because there is a localised obesity component, I add a further homeopathic complex to the syringe formulated on the base of Graphites, Levothyroxine, Fucus, AMP-c, ATP, and Triac called METABOLITES, given that homeopathic formulations enable me to mix several products in the one syringe, which also boost each other.

8. SURGERY: We are going to comment on the two most widely-used techniques in body remodelling, and therefore, on actions carried out on cellulitis and localised adiposities. I refer of course to Liposuction and the more modern Ultrasonic Liposuction. Basically, both consist of the same thing, namely, the introduction of a cannula, either a simple one, or one connected to an ultrasound apparatus which acts by breaking up the fatty cells by means of a minimal incision in the skin, and by sucking the fatty masses that go to make up the unaesthetic mark that we wish to remove. These are techniques, which, in the hands of experts manage to achieve extraordinary results and are practically risk free. Nevertheless, we must bear in mind a series of considerations: basically, we are dealing with a surgical act, and therefore, it requires that the doctor in question receive special medical training in order to use the technique. We must also not forget the fact that not all cases of cellulitis can be operated on, and that proper professional criteria must prevail when it comes to selecting candidate patients for intervention. These criteria refer to a minimum guarantee of success and a minimisation of the operatory risks. Furthermore, we must provide the patient with complete and extensive information on the phases and characteristics of the intervention and of the postoperatory factors that are essential to complete success. It is quite regrettable that solely in the interests of making money, absolutely “everything” is being operated on, in many cases without the required experience and failing to respect essential conditions of habitability (operating theatres, sterile rooms, suitable anaesthesia etc.) required to at least assuring the safety of the patients. For this very reason, I always point out the fact that good information is essential when it comes to deciding on a technique, or on one professional or another. A lot of the time, it is better to exercise caution, rather than later regret something which cannot be remedied.

After this review of all of the therapeutic possibilities that we have available to us, the solution to the problem can be summed in what we have already said: An “intensive” anti-cellulitic treatment does not exist, however, there does exist a set of effective treatments. Cellulitis can be cured, and this we can state categorically, but always stressing the fact that constancy is the best ally when it comes to combating cellulitis. The more arms we employ, the better the results will be. And this is the ideal point at which to state, unfortunately, anti-cellulitic treatment has no end. Just as important as a proper approach to treatment at the beginning, is the maintenance treatment with a booster dose to ensure that what we have managed to cure will not reappear. We must also bear in mind that a change in our daily customs is also needed in order to prevent us from being plagued by this unpleasant disease.