Cellulite or lipoedema: how to tell the difference

Many women spend years hearing that thick legs are “cellulite” or “excess weight”. They go on diets, exercise, anti-cellulite treatments. The trunk slims down, but the legs do not change. They hurt to the touch, bruise easily and seem to belong to another body. Often, only after a long time does someone put a name to what they have: lipoedema.

Lipoedema and cellulite can coexist, which is why they are confused. But they are very different things. Cellulite is a skin characteristic present in most women. Lipoedema is a chronic, painful disease of the adipose tissue that deserves medical diagnosis and follow-up.

What lipoedema is

Lipoedema was first described in 1940, at the Mayo Clinic in the United States (Allen and Hines, 1940). For decades it was little known and often confused with obesity, cellulite or lymphoedema. In recent years it has gained recognition: the World Health Organization included it in the International Classification of Diseases (ICD-11) and the German Society of Phlebology and Lymphology published, in 2024, an updated clinical guideline (S2k), one of the most complete references on the subject.

According to that guideline, lipoedema is a painful, symmetrical and disproportionate alteration in the distribution of adipose tissue in the limbs, occurring almost exclusively in women. It does not affect the trunk, head, neck, hands or feet.

What is still not known

• The exact cause is not clear. It is thought to involve genetic factors (there is often a family history) and hormonal ones, because it appears or worsens in phases of hormonal change: puberty, pregnancy, starting contraceptives, perimenopause.
• The frequency is uncertain. The figures in circulation vary greatly, because diagnostic criteria have not been uniform and many cases are not diagnosed.

Lipoedema is not obesity, but they can coexist

The guideline is clear: lipoedema is not caused by obesity and does not cause obesity. But obesity is common in women with lipoedema and can make it worse. One important point: body mass index (BMI) can be misleading, because limb fat raises it. That is why it is recommended to combine BMI with the waist-to-height ratio.

Always progressive?

Not necessarily. The 2024 guideline states that lipoedema is not necessarily progressive. Its course depends on factors such as weight gain and hormonal changes, which should be assessed case by case.

The typical signs of lipoedema

1. Pain. This is the central sign. Pain on pressure or touch, spontaneous pain, a feeling of heaviness and tiredness in the legs, often worse at the end of the day, in hot weather or in the premenstrual phase. The 2024 guideline is explicit: without pain complaints, the diagnosis of lipoedema should not be made.

2. Disproportion. The legs (and sometimes the arms) have much more volume than the trunk. It is common to wear one size on top and two or three sizes larger below.

3. Symmetry. It affects both sides similarly.

4. Feet and hands spared. The fat stops abruptly above the ankle, creating a kind of “cuff” or step between the leg and the foot, which looks normal. The same can happen at the wrist.

5. Easy bruising. They appear with slight knocks, often without the person remembering having bumped into anything.

6. Little response to diet and exercise in the affected limbs. The trunk and face slim down; the legs change little.

7. Onset in hormonal phases. Puberty, pregnancy, contraceptives, perimenopause.

8. Family history. Mothers, sisters, grandmothers with similar legs.

Patterns and stages

Lipoedema can affect mainly the hips and thighs, the whole legs, only the lower part of the legs, or the arms as well. There are classifications in stages (smooth skin, uneven skin with nodules, large folds of tissue) that describe its appearance. The 2024 guideline notes, however, that these stages describe the form but do not measure severity, and that the “granular” or nodular appearance of the tissue should not be used as a diagnostic criterion. What weighs most on patients' lives is pain, limitations and the psychological impact.

Side by side: cellulite, lipoedema, obesity and lymphoedema

In practice, these conditions can overlap. A woman with lipoedema may also have cellulite, be overweight and, in advanced stages, develop a lymphoedema component (lipolymphoedema). That is why the diagnosis should be made by a doctor with experience.

A simple test that does not replace diagnosis

Ask yourself these questions:

• Are my legs clearly bigger than the rest of my body, and have they always been, or did they become so at a hormonal stage?
• Do they hurt when I touch them or when someone squeezes them?
• Do I bruise very easily on my legs?
• Do my feet look “normal” compared with my legs?
• When I lose weight, are the legs the last to change, or do they not change?

If you answered yes to several, it is worth speaking to a doctor about lipoedema.

How the diagnosis is made and who to turn to

The diagnosis of lipoedema is clinical: it is based on the history and observation. There is no blood test, ultrasound, MRI or lymphoscintigraphy that confirms it.

Tests are used to rule out other causes of bulky or swollen legs:

• Tests of thyroid and kidney function, and markers of heart failure, when indicated.
• Venous ultrasound, if vein disease is suspected.
• Lymphatic tests, if lymphoedema is suspected.

Who can assess

In Portugal, lipoedema is assessed mainly in angiology and vascular surgery clinics, physical and rehabilitation medicine (with experience in lymphology) and, sometimes, dermatology or plastic surgery. The family doctor can make the first assessment and refer you.

Signs not to put off

Not every increase in leg volume is lipoedema. Seek assessment quickly if you have:

Treatment: what helps and what doesn't

There is no cure for lipoedema, but there is effective treatment for the symptoms and for quality of life. The approach is generally combined and long term.

Conservative treatment

• Compression: compression stockings or trousers (often flat-knit, made to measure) reduce pain, the feeling of heaviness and associated swelling.
• Manual lymphatic drainage and complex decongestive therapy: useful above all when there is an associated oedema or lymphoedema component. They relieve symptoms, but do not reduce the fat of lipoedema.
• Exercise: low-impact activities (water, cycling, walking) and moderate strength training improve mobility, pain and general health. The 2024 guideline includes them among the recommended measures.
• Weight control: it does not eliminate lipoedema, but avoiding or treating associated obesity is important, because obesity worsens the symptoms.
• Psychological support: the guideline recommends assessing the psychological impact from the first consultation. The relationship with the body, years of wrong diagnoses and stigma weigh heavily. If you feel this is affecting your wellbeing, speak to your doctor; you can also call SNS 24 (808 24 24 24).

Surgical treatment

Liposuction using techniques that spare the lymphatic vessels may be indicated in selected cases, especially when pain and limitations persist despite conservative treatment. Follow-up studies (Baumgartner et al., 2021) describe sustained reductions in pain and pressure sensitivity over several years. It is a surgical procedure with its own risks, which should be decided with a surgeon experienced in lipoedema.

And aesthetic treatments?

Here we need to be clear:

• Anti-cellulite treatments do not treat lipoedema. They may improve the appearance of the skin, but not the disease.
• “Localised fat reduction” treatments do not replace medical treatment and some (with intense heat, intense cold or strong pressure) can be uncomfortable or contraindicated in painful tissue. They should be discussed with the doctor who is following the lipoedema.
• Manual lymphatic drainage, carried out by trained professionals, may play a complementary role in relieving swelling and discomfort.
• Skincare (moisturising, caring for the skin under compression) improves comfort.

This article is for information purposes and does not replace a medical consultation. The diagnosis of lipoedema should be made by a doctor.

Frequently asked questions