The stages of cellulite and how doctors grade them
Cellulite is staged most often on a 1978 scale by Nürnberger and Müller, from stage 0 to stage III, judged standing, lying down and with a pinch. Researchers also use the 2009 Hexsel score, five features rated 0 to 3, and a 2020 photo scale from 0 to 4. The 1978 scale has no stage 4.
Published · Written by Kay Woodson · Results vary.The Nürnberger-Müller stages, 0 to III
Published in 1978 in the Journal of Dermatologic Surgery and Oncology. It is still the scale most studies name. The wording below is the scale as reproduced in a 2017 cellulite drug trial protocol.
| Stage | What it means | How it is seen |
|---|---|---|
| 0 | No alteration of the skin surface | Nothing shows, even with a pinch |
| I | The skin is smooth while standing or lying, but changes appear when the skin is pinched or the muscle is tightened | Pinch test or muscle contraction |
| II | The orange-skin or mattress look is evident when standing, without any pinching or contraction | Standing, relaxed |
| III | The stage II changes, plus raised areas and nodules | Standing, relaxed |
Four stages in all, which is why some papers call it a 4-stage scale. Source: Nürnberger and Müller, 1978, wording from Table 9 of Endo's EN3835-202 protocol.
How to check your own stage at home
- 1Stand in side lightStand relaxed, muscles loose, with light coming from one side. Side light shows texture that overhead light hides. If you see dimpling or an orange-peel look without touching anything, you are at stage II or higher.
- 2Look for raised areasWith the dimpling, do you also see raised patches or small firm bumps? That is the line between stage II and stage III.
- 3Pinch gentlyIf the skin looks smooth, take a fold between your thumb and index finger, or tighten the muscle under it. Dimpling that appears only then is stage I. Nothing at all is stage 0.
- 4Write it down with a dateNote the stage, the area, the light and the date, and take a photo from the same distance. That makes any later change easier to judge.
A stage is a description, not a diagnosis
The 1978 paper that created this scale was titled "So-called cellulite: an invented disease." Its authors described cellulite as normal in women and close to inevitable. A higher stage means more visible texture. It says nothing about your health. Pain, swelling or easy bruising is a different matter: see a physician.
The Hexsel Cellulite Severity Scale, 2009
Hexsel and colleagues built it from standardized photos of 55 patients, published in the Journal of the European Academy of Dermatology and Venereology. Each of five features scores 0 to 3. The total is the sum, so it runs from 0 to 15.
| Feature | 0 | 1 | 2 | 3 |
|---|---|---|---|---|
| Number of visible depressions | None | 1 to 4 | 5 to 9 | 10 or more |
| Depth of depressions | None | Superficial | Medium | Deep |
| Look of the skin surface | No raised areas | Orange peel | Cottage cheese | Mattress |
| Laxity or sagging | None | Slight draped look | Moderate draped look | Severe draped look |
| Nürnberger-Müller stage | Stage 0 | Stage I | Stage II | Stage III |
The paper sorts totals into mild, moderate and severe. Assessed standing, with relaxed muscles. Wording from Table 9 of Endo's EN3835-202 protocol, which cites Hexsel 2009.
Why a second scale was needed
The 1978 stages describe what you see but not how much of it. Two women can both be stage II, one with three shallow dimples and one with a dozen deep ones. Hexsel's score counts the dimples, rates their depth and adds loose, draped skin, which the old scale leaves out.
That last feature matters as women age. Sagging skin can make dimpling look deeper, and a treatment aimed at cellulite may do nothing for laxity. A score that separates the two helps you see which one you are actually bothered by.
The 2020 trial scale: where a "4" comes from
When Endo Pharmaceuticals tested its cellulite injection, the company and its researchers built two photo scales: one for clinicians (CR-PCSS) and one for patients (PR-PCSS). Both have 5 levels, from 0 (none) to 4 (severe), with separate versions for the buttocks and the thighs. The validation paper, funded by Endo, appeared in Dermatologic Surgery in December 2020 and found that a 1-point change was clinically meaningful.
So if you read about "stage 4" or "grade 4" cellulite, ask which scale is meant. On this trial scale, 4 is the most severe level. On the 1978 scale, the top is stage III.
One more detail for darker skin. Photo scales judge shadows and texture. In the pooled trial data behind the clinician scale, 40.4% of the 793 women had Fitzpatrick skin types IV to VI, and the authors still listed the limited range of skin tones as a weakness. If your skin is deep brown, ask whoever grades you to use the same light and angle every time.
Why your stage matters when you read a study
Studies enroll people at set stages. A result for one stage may not carry over to yours.
| Study or product | Who or what it covers | Scale used |
|---|---|---|
| Endermologie, Güleç, 2009 | 33 women at grades 1 to 3 | Nürnberger-Müller, 4 stages |
| QWO injection | Approved use: moderate to severe cellulite in the buttocks of adult women | CR-PCSS and PR-PCSS in its trials |
| LPG Endermologie FDA file, 2000 | No stage named. Wording: temporarily reduces the appearance of cellulite | None |
QWO's maker stopped producing and selling it on December 6, 2022. Karisma does not offer it.
Bringing your stage to Karisma
Karisma Esthetics offers LPG Endermologie for cellulite on the stomach, thighs, hips and buttocks: $160 for the first visit with the consultation, then $150 per 60-minute session. Its effect on how cellulite looks is temporary, and results vary.
Bring your own notes and photos to the first visit, and ask Kay what a series can and cannot change at your stage. For the study figures behind Endermologie, read does Endermologie work for cellulite?
Questions about cellulite stages
What is stage 4 cellulite?
The original 1978 scale has no stage 4: it ends at stage III, where dimpling shows standing and comes with raised areas and nodules. A 2020 photo scale used in drug trials runs from 0 to 4, with 4 meaning severe. Lipedema, a separate medical condition, has its own stages 1 to 4. See lipedema vs cellulite.
What does stage 1 cellulite look like?
Smooth skin, standing or lying down. The dimpling only shows when you pinch the skin or tighten the muscle under it.
Can cellulite go down a stage?
Average grades did drop in a 2009 Endermologie study of 33 women, yet only 5 of them looked visibly smoother in photos. A lower score and a change you can see are not always the same thing.
Is Cleveland Clinic's 0 to 3 grading the same scale?
It is a simpler 4-grade description, from 0 for none to 3 for severe dimples standing or sitting. Our guide to cellulite on the legs walks through it.
- Nürnberger F, Müller G. So-called cellulite: an invented disease. J Dermatol Surg Oncol 1978;4(3):221-229, March 1978, checked October 29, 2026
- Hexsel DM, Dal'Forno T, Hexsel CL. A validated photonumeric cellulite severity scale. J Eur Acad Dermatol Venereol 2009;23(5):523-528, May 2009, checked October 29, 2026
- Endo Pharmaceuticals, EN3835-202 protocol, Table 9 (Hexsel scale and Nürnberger-Müller stages, verbatim), ClinicalTrials.gov NCT02942160, protocol dated June 6, 2017, read October 29, 2026
- Cohen JL et al. Development and validation of clinician and patient reported photonumeric scales to assess buttocks cellulite severity. Dermatologic Surgery 2020;46(12):1628-1635, December 2020, read October 29, 2026
- Güleç AT. Treatment of cellulite with LPG endermologie. Int J Dermatol 2009;48(3):265-270, March 2009
- Endo to cease production and sale of QWO, Endo International press release, December 6, 2022
- Cellulite, Cleveland Clinic, last updated October 28, 2021, checked October 29, 2026
- Lipedema, Cleveland Clinic, last updated June 1, 2023
- FDA 510(k) K990445, LPG Therapeutic Massager, decision January 18, 2000