Lipedema vs. Cellulite: Understanding the Differences and Diagnoses

The pressure of societal beauty standards can affect mental health. Research highlights the high prevalence of body dissatisfaction related to fat distribution, especially among women.  

The lack of clarity between conditions like lipedema and cellulite often adds to the frustration and confusion surrounding these issues. Both can significantly affect an individual's confidence and quality of life, but their causes, symptoms, and implications are fundamentally different. 

Clarifying the distinctions between lipedema and cellulite through evidence-based information is essential for proper diagnosis and effective management, ensuring those affected can access the appropriate care and support they need.

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Understanding Lipedema

Lipedema is a chronic condition characterized by symmetrical fat accumulation, primarily in the lower extremities. It is estimated to affect one in 72,000 people and 11% of women; however, these are likely underestimated because lipedema can be misdiagnosed as obesity or lymphedema (a buildup of lymph fluid in the tissues, causing swelling).

Lipedema is classified into several types based on the regions of the body affected. Multiple types can affect one person at a time. For example, Type II and IV or III and IV are common combinations. 

• Type 1: fat distribution from the belly button to the hips, including the pelvis, hips, and buttocks
• Type II: fat distribution from the pelvis to the knees
• Type III: fat distribution from the pelvis to the ankles
• Type IV: fat distribution from the shoulders to wrists
• Type V: fat distribution from below the knees to the ankles

Causes of Lipedema

The exact causes of lipedema are not fully understood, but it is believed to result from a combination of genetic, hormonal, and vascular factors. 

Genetic predisposition plays a significant role, as lipedema often runs in families. A positive family history has been noted in 60-80% of cases. Studies suggest that lipedema may be inherited in a way that requires only one copy of a specific mutated gene, but not all that inherit the gene are guaranteed to develop lipedema (23).

‍Hormonal factors are also implicated in the onset and progression of lipedema because the condition predominantly affects women and typically manifests or worsens during periods of hormonal change, such as puberty, pregnancy, or menopause.

Vascular factors may contribute to the development of lipedema as well. There is evidence of microangiopathy (small vessel disease) in affected individuals, leading to increased permeability of blood vessels and subsequent fat accumulation in the tissues. This vascular dysfunction can result in the pain, tenderness, and easy bruising commonly experienced by lipedema patients. (23)

Identified risk factors for lipedema include:

• Assigned female at birth
• Family history of lipedema
• Body mass index (BMI) greater than 35

Signs and Symptoms of Lipedema

Symptoms of lipedema include:

• Symmetrical buildup of fat in the lower and/or upper extremities that spares the hands and feet
• Firm nodules of fat tissue below the skin that can feel like rice, peas, or walnuts
• Pain that varies in severity and frequency
• A sensation of heaviness or pressure in the affected limbs
• Easy bruising
• Fatigue
• Inability to lose weight through exercise and diet

Lipedema progresses through four stages, each reflecting increasing severity. 

• Stage 1: smooth skin with an increase of enlarged subcutaneous fat tissue
• Stage 2: uneven skin characterized by indentations and irregular texture
• Stage 3: large protrusions of fat and significant deformation of the affected limbs
• Stage 4 (Lipolymphedema): lipedema associated with lymphedema

Understanding Cellulite

Cellulite is a common cosmetic condition characterized by a dimpled or lumpy appearance of the skin, often described as having an "orange peel" texture. Cellulite is not a medical condition but a normal variation in how fat is stored beneath the skin. It is highly prevalent, affecting approximately 80-90% of post-pubertal women to some degree. Men are less commonly affected, with a prevalence rate of less than 10%. 

Causes of Cellulite

Cellulite forms when the connective tissue between the skin and the underlying fat and muscles tighten irregularly, causing puckering of the skin. It's not exactly known what causes it, but the following factors appear to be drivers of cellulite formation: 

• Genetics
• High levels of estrogen and insulin
• Weight gain
• Lack of exercise
• Smoking
• Aging (3, 9, 32) 

Signs and Symptoms of Cellulite

The primary sign of cellulite is the dimpled appearance of the skin. It most commonly affects the thighs and buttocks but can also occur on the breasts, abdomen, and upper arms. (3) 

Cellulite can be graded based on its severity: 

• Grade 0: no visible cellulite
• Grade 1 (Mild): the skin appears smooth when standing or lying down, but dimpling becomes noticeable when the skin is pinched or muscles are contracted
• Grade 2 (Moderate): skin dimpling is visible while standing but not lying down; the texture of the skin shows more pronounced irregularities without pinching the skin
• Grade 3 (Severe): skin dimpling is visible when standing and lying down; the skin has deep depression and nodules, and the uneven  texture is evident without pinching the skin or contracting the muscles

Key Differences Between Lipedema and Cellulite

While lipedema and cellulite may look similar, given the uneven appearance of skin they cause, these are two distinct conditions that require different management approaches.

Lipedema is a medical condition associated with functional impairments and potential health complications. The fat accumulation in lipedema is resistant to diet and exercise and can lead to a disproportionate appearance between the upper and lower body. Lipedema can cause significant discomfort, including pain, tenderness, and a sensation of heaviness or pressure in the affected areas. Some individuals may also bruise easily. Beyond the physical discomfort, lipedema can lead to reduced mobility, lower quality of life, depression, disordered eating, and an increased risk of lymphatic, vascular, and joint issues. (25) 

On the other hand, cellulite is a cosmetic condition that does not require treatment. It rarely causes symptoms and may be barely noticeable in mild cases. Cellulite can negatively impact body image but is not known to cause any other long-term health effects. 

Diagnosis and Medical Evaluation

Lipedema and cellulitis both require a clinical diagnosis, meaning blood tests or imaging cannot confirm their presence. Both should be diagnosed with a comprehensive patient history and physical exam.

Lipedema 

Clinical diagnostic criteria for lipedema include:

• Family history of lipedema
• Bilateral, symmetrical, and disproportionate fatty tissue accumulation on the limbs that spares the hands and feet 
• A feeling of heaviness and tension in the affected limbs
• Pain to pressure and touch
• No reduction of volume and/or pain when raising extremities
• Tendency to bruise 
• Stable limb circumference with weight reduction or caloric restriction
• Worsening of symptoms over the day
• Minimal edema

Doctors are encouraged to perform the Stemmer sign test, in which the examiner pinches the and attempts to lift a fold of skin, typically on the second toe or finger. If you can pinch, the Stemmer sign is negative. If you cannot pinch, the Stemmer sign is positive, suggesting lymphedema. (14)  

Imaging is not required for diagnosis, but the skin and subcutaneous tissues can be studied with ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) (23).  

Lymphoscintigraphy is an imaging technique used to assess lymphatic function and detect any associated abnormalities. During the procedure, a radioactive tracer is injected into the tissues, allowing clinicians to track its movement through the lymphatic system using specialized imaging equipment. This helps identify impaired lymphatic drainage patterns, which are common in advanced lipedema stages.

Cellulite

Cellulite is easily diagnosed with a skin exam based on its characteristic appearance. 

Management and Support

A multidisciplinary approach can improve outcomes in both conditions. 

Lipedema

The goals of managing lipedema include:

• Manage inflammation and pain
• Support lymphatic flow
• Address adipose tissue concerns
• Promote emotional/mental health

There is no cure for lipedema, but conservative measures can help manage symptoms and improve a patient's quality of life. Conservative management may lessen pain and tightness in the limbs and reduce tissue volume by 5-10%. Components include:

• Manual lymphatic drainage
• Compression stockings
• Exercise therapy to address strength, flexibility, and conditioning
• Psychological support
• Dietary guidance
• Weight management

There is no specific dietary plan most effective for patients with lipedema. Dietary plans should be designed to support healthy body weight (as needed) and reduce systemic inflammation. Because many patients with lipedema have eating disorders, establishing care with a psychologist, nutritionist, and/or registered dietician can be helpful to prevent and address disordered thinking around food. 

Antioxidant and anti-inflammatory supplements may help add another layer of support to reduce pain and inflammation. Examples include:

• Omega-3 fatty acids
• Curcumin
• Glutathione
• Resveratrol
• Selenium

Lymph-sparing liposuction may be considered as a surgical option to remove fat and help with pain and mobility in the advanced stages of the condition.

Cellulite

Many lifestyle modifications can help manage the appearance of cellulite:

• Eat a calorie-controlled, low-glycemic, anti-inflammatory diet to support weight management and address insulin resistance
• Exercise regularly, focusing on both aerobic and resistance training to tone muscle and support fat management
• Stop smoking 
• Reduce or eliminate alcohol consumption

According to the American Academy of Dermatology (AAD), the following topical medications and medical procedures may help reduce the appearance of cellulite: 

• Acoustic Wave Therapy: a handheld device that delivers high-energy acoustic waves to targeted skin areas. These waves penetrate the skin and underlying tissues, stimulating collagen production, enhancing blood circulation, and breaking down fat deposits. It may take several sessions to work.
• Laser Therapy: laser energy breaks up tissue and thickens skin to reduce the appearance of cellulite for up to one year.
• Sibcision: a needle is inserted under the skin to break up connective tissue bands. This procedure may result in 99% patient satisfaction and lasting results for up to two years.
• Vacuum-Assisted Precise Tissue Release: a device containing small blades cuts connective tissue bands under the skin. As the bands are cut, the underlying tissues move up to fill the space under the skin and eliminate dimpling. 
• Topical creams containing caffeine or retinol act to reduce cellulite via different mechanisms. Consistent daily application is required to see results over time.

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Key Takeaways

• Lipedema and cellulite are distinct conditions with critical differences in their fat distribution, symptoms, and impact on health. Lipedema involves symmetrical fat accumulation in the extremities, accompanied by pain, tenderness, and potential mobility issues, classifying it as a medical condition requiring comprehensive management. In contrast, cellulite is a cosmetic concern characterized by a dimpled skin appearance, primarily affecting the thighs, buttocks, and abdomen, without causing significant physical discomfort. 
• Accurate diagnosis and evidence-based management are needed to address both conditions effectively and ensure that patients receive appropriate care tailored to their needs.
• Anyone experiencing symptoms of lipedema or concerns about cellulite should speak with a healthcare professional for advice on proper diagnosis and management. 
• Ongoing research and increased awareness will continue to improve patient outcomes, particularly for lipedema, which remains underdiagnosed and often misunderstood. Enhanced understanding and innovative management approaches can lead to a better quality of life for those affected by these conditions.