A Pilot Study of Cutaneous Ultrasound Evaluation of Structural Changes in Subcutaneous Tissue in Patients With Cellulitis After Multidisciplinary Treatment to Combat Cellulitis (PnKCelulitis® Program)
Conditions: Cellulite
Sponsor: Protein Supplies SL

PNKCELULITIS STUDY 
Pilot study for ultrasound evaluation of structural changes in 
subcutaneous tissue in patients with cellulite after a 
multidisciplinary anti-cellulite treatment 
 (PnKcelulitis program®) 
STUDY PROTOCOL 
Protocol Code: PNK-CEL-2016-06 
(Version 1.0 dated 05 May, 2016) 
Principal investigator:  
Dr. Esther Roe 
Department of Dermatology. 
Hospital de la Santa Creu i Sant Pau 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
after a multidisciplinary  anti-cellulite treatment (PnKcelulitis program). PNKCELULITIS Study  
 
PNK-CEL-2016-06 Version 1.0 dated 05 May, 2016 
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1 ABSTRACT 
 
1.1 Type of study 
A pilot, prospective, single blind, no controlled study with ultrasound evaluation of skin 
in patients undergoing treatment with a multidisciplinary program that includes diet, 
physical exercise and cosmetic cream.   
 
1.2 Sponsor's identification 
PNKDIET, S.L.U.  
C/ Roger de Llúria, 58.  
08009 Barcelona  
Tel: +34 934 877 589.  
 
1.3 Study title 
Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in 
patients with cellulite after a multidisciplinary anti-cellulite treatment (PnKcelulitis 
program). PNKCELULITIS Study 
 
1.4 Protocol Code: 
PNK-CEL-2016-06 
 
1.5 Principal investigator: 
Dr. Esther Roe 
Department of Dermatology. 
Hospital de la Santa Creu i Sant Pau 
 
1.6 Research collaborator 
Dr. Esther Serra Baldrich 
Department of Dermatology. 
Hospital de la Santa Creu i Sant Pau 
 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
after a multidisciplinary  anti-cellulite treatment (PnKcelulitis program). PNKCELULITIS Study  
 
PNK-CEL-2016-06 Version 1.0 dated 05 May, 2016 
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1.7 Study location   
Department of Dermatology. 
Hospital de la Santa Creu i Sant Pau 
Barcelona (Spain) 
 
1.8 Study design 
Prospective, no controlled pilot study on the structural changes in subcutaneous tissue 
observed by skin ultrasound, in patients with edematous fibrosclerotic panniculopathy 
(cellulite) after a multidisciplinary treatment program including diet, physical exercise 
and cosmetic cream.   
 
1.9 Primary objective  
To evaluate the structural changes (trabecular texture) in subcutaneous tissue detected 
by skin ultrasound in patients with cellulite after a multidisciplinary treatment that 
includes diet, physical exercise and cosmetic cream. 
 
1.10 Secondary objectives 
• To evaluate changes in skin thickness assessed by skin ultrasound after 
multidisciplinary treatment. 
• To evaluate the changes in cellulite severity in the involved areas after the 
multidisciplinary treatment from photographic images. 
 
1.11 Disease in study 
Non-infectious skin cellulite or edematous fibrosclerotic panniculopathy 
 
1.12 Therapy in study 
Multidisciplinary program including diet, physical exercise and cosmetic cream 
(PnKCelulitis® program) 
 
1.13 Primary Outcome Measure 
Differences in trabecular structure of subcutaneous tissue between prior to starting 
multidisciplinary treatment and after the end of this treatment, assessed by skin 
ultrasound.  
 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
after a multidisciplinary  anti-cellulite treatment (PnKcelulitis program). PNKCELULITIS Study  
 
PNK-CEL-2016-06 Version 1.0 dated 05 May, 2016 
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1.14 Study population and number of subjects 
Women with non-infectious skin cellulite (edematous fibrosclerotic panniculopathy), 
submitted to the PnKCelulitis® multidisciplinary treatment program including diet, 
physical exercise and cosmetic cream. 
The number of patients expected to be included is 30. 
 
1.15 Follow-up and duration of the study  
Patient follow-up will be 10 ± 1 weeks to 18 ± 1 weeks, depending of treatment duration 
because of the degree of cellulite.    
 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
after a multidisciplinary  anti-cellulite treatment (PnKcelulitis program). PNKCELULITIS Study  
 
PNK-CEL-2016-06 Version 1.0 dated 05 May, 2016 
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2 INDEX  
 
1 ABSTRACT ............................................................................................................. 2 
1.1 
Type of study ......................................................................................... 2 
1.2 
Sponsor's identification .......................................................................... 2 
1.3 
Study title ............................................................................................... 2 
1.4 
Protocol Code: ....................................................................................... 2 
1.5 
Principal investigator: ............................................................................. 2 
1.6 
Research collaborator ............................................................................ 2 
1.7 
Study location ........................................................................................ 3 
1.8 
Study design .......................................................................................... 3 
1.9 
Primary objective ................................................................................... 3 
1.10 
Secondary objectives ............................................................................. 3 
1.11 
Disease in study .................................................................................... 3 
1.12 
Therapy in study .................................................................................... 3 
1.13 
Primary Outcome Measure .................................................................... 3 
1.14 
Study population and number of subjects .............................................. 4 
1.15 
Follow-up and duration of the study ....................................................... 4 
2 INDEX ...................................................................................................................... 5 
3 GENERAL INFORMATION ...................................................................................... 7 
4 INTRODUCTION AND RATIONALE OF THE STUDY ............................................. 8 
5 STUDY OBJECTIVES ............................................................................................. 9 
5.1 
Primary objective ................................................................................... 9 
5.2 
Secondary objectives ............................................................................. 9 
6 STUDY DESIGN ...................................................................................................... 9 
6.1 
Type of study ......................................................................................... 9 
6.2 
Randomization process ......................................................................... 9 
6.3 
Type of control ....................................................................................... 9 
6.4 
Masking Techniques ............................................................................ 10 
7 SUBJECT SELECTION ......................................................................................... 10 
7.1 
Study population .................................................................................. 10 
7.2 
Inclusion criteria ................................................................................... 10 
7.3 
Exclusion criteria.................................................................................. 10 
7.4 
Number of subjects .............................................................................. 11 
7.5 
Rationale of sample size ...................................................................... 11 
7.6 
Recruitment period .............................................................................. 11 
7.7 
Criteria for withdrawal or dropouts ....................................................... 11 
 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
after a multidisciplinary  anti-cellulite treatment (PnKcelulitis program). PNKCELULITIS Study  
 
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8 TREATMENT DESCRIPTION ................................................................................ 11 
Multidisciplinary program for the treatment of cellulite ............................................. 11 
9 STUDY MEASUREMENTS AND ENDPOINTS ...................................................... 12 
9.1 
Study endpoints ................................................................................... 12 
9.1.1 
Primary endpoint ............................................................................................... 12 
9.1.2 
Secondary endpoints ......................................................................................... 12 
9.2 
Study plan and procedures .................................................................. 13 
9.2.1 
Recruitment of patients ..................................................................................... 13 
9.2.2 
Follow-up of patients ......................................................................................... 13 
9.2.3 
Procedure for taking photographs ..................................................................... 14 
9.2.4 
Procedure for the assessment of skin ultrasound ............................................. 14 
10 STATISTICAL ANALYSIS ..................................................................................... 15 
10.1 
Descriptive statistics ............................................................................ 15 
10.2 
Analysis of objectives .......................................................................... 15 
10.3 
Responsibility for statistical analysis .................................................... 15 
11 REPORT OF ADVERSE EVENTS ......................................................................... 15 
12 ETHICAL ISSUES.................................................................................................. 16 
12.1 
General considerations ........................................................................ 16 
12.2 
Evaluation by an Authorized Clinical Research Ethics Committee ....... 17 
12.3 
Patient information and informed  consent ........................................... 17 
12.4 
Data confidentiality .............................................................................. 17 
13 PRACTICAL CONSIDERATIONS ......................................................................... 17 
13.1 
Workplan ............................................................................................. 17 
13.2 
Monitoring ............................................................................................ 17 
13.3 
Financing the study .............................................................................. 18 
13.4 
Disseminating the study results ........................................................... 18 
14 REFERENCES ....................................................................................................... 18 
 
 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
after a multidisciplinary  anti-cellulite treatment (PnKcelulitis program). PNKCELULITIS Study  
 
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3 GENERAL INFORMATION  
Study title 
Pilot study for ultrasound evaluation of structural changes in 
subcutaneous tissue in patients with cellulite after a 
multidisciplinary  anti-cellulite treatment (PnKcelulitis® 
program). PROCESS study 
Protocol Code: 
PNK-CEL-2016-06 
Type of study 
A pilot, prospective, single blind, no controlled study with 
ultrasound evaluation of skin in patients undergoing 
treatment with a multidisciplinary program that includes diet, 
physical exercise and cosmetic cream.   
Therapy in study 
Multidisciplinary program  including diet, protein 
supplements, physical exercise and cosmetic cream 
(PnKCelulitis® program) 
Sponsor's details 
PNKDIET, S.L.U.  
C/ Roger de Llúria, 58.  
08009 Barcelona  
Tel: +34 934 877 589. 
Principal investigator: 
Dr. Esther Roe 
Department of Dermatology. 
Hospital de la Santa Creu i Sant Pau 
Research collaboration 
Dr. Esther Serra Baldrich 
Department of Dermatology. 
Hospital de la Santa Creu i Sant Pau 
Primary objective 
To evaluate the structural changes (trabecular texture) of 
subcutaneous tissue detected by skin ultrasound in patients 
with cellulite after a multidisciplinary treatment that includes 
diet, physical exercise and cosmetic cream. 
Study population 
Women with non-infectious skin cellulite (edematous 
fibrosclerotic panniculopathy), submitted to the 
PnKCelulitis®multidisciplinary program  including diet, physical 
exercise and cosmetic cream. 
No. of subjects 
A pilot study is expected to include 30 patients  
Follow-up  
Patient follow-up will be 10 ± 1 weeks to 18 ± 1 weeks, 
depending on the degree of cellulite. With two controls: initial 
and final 
 
 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
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4 INTRODUCTION AND RATIONALE OF THE STUDY  
Cellulite is a skin disorder that modifies the subcutaneous adipose tissue causing 
changes in the body shape and skin. It is accompanied by changes in the 
microcirculation of the connective tissue, causing morphological, histochemical and 
biochemical modifications to the tissue. It is characterized by the padded and nodular 
appearance of the skin in sloping areas.  
Also 
known 
as 
'deforming 
skin 
panniculitis', 
'nodular 
lipodermatosclerosis', 
'gynecological lipodystrophy' or 'edematous fibrosclerosis', among others, it is a 
disorder that affects 85-98% of women after puberty and is considered a women's 
secondary sexual feature1,2.   
With a multifactorial etiology, its physiopathology is complex and includes: expansion of 
the subcutaneous fat, formation of fibrotic septa in the dermis, dermal laxity and 
atrophy3.  
In addition to the direct effect of hormonal changes; genetic factors ,a family tendency 
to abnormal fat deposition and poorly developed muscle mass are some of the factors 
influencing the development of cellulite.  Bad eating habits are other non-hormonal risk 
factors for the development of cellulite. Increased intake of carbohydrates and fats 
increases hyperinsulinemia which, among other effects, intensifies the lipogenesis 
process. Also, a poorly balanced diet with a lot of preservatives and salt in food 
increases fluid retention and edema.4.   
Some additional factors are poor physical exercise and a sedentary lifestyle that disrupt 
the proper functioning of microcirculation and support the accumulation of adipose 
tissue4. 
A wide range of therapies have been suggested for the treatment of cellulite, from 
weight loss (the most frequent), to treatments of skin massage and the use of topical 
agents and oral supplements. Massages reduce edema and there is also some 
evidence of increased collagen synthesis after such treatments. Likewise, their benefits 
might be explained by their likely effects on fibroblast activity stimulation and 
decreased adipocyte activity. Generally, topical creams contain different agents but 
have been poorly studied. Xanthines, botanical extracts, fragrances, and retinoid and 
PPAR receptors ligands seem to provide some results, through the reduction of 
adipogenesis and an increased thermogenesis that would improve microcirculation and 
the collagen synthesis. In addition, many oral agents for weight control (hydroxycitrate, 
epigallocatechin gallate, conjugated linoleic acid, etc.) are being researched and some 
of these agents, such as conjugated linoleic acid (CLA), seem to improve the signs of 
cellulite. Regular exercise and a proper diet can help control weight and therefore the 
appearance of cellulite.2 
The PnKCelulitis® Program is a new treatment aimed at improving the signs of cellulite 
by combining different types of therapies. Its multidisciplinary approach includes: diet, 
physical exercise and the topical application of a cream. The dietary regimen includes 
a hypocaloric diet and protein supplements. The diet, which in the first few weeks is 
also ketogenic with a very restricted supply of carbohydrates, is able to increase 
lipolysis and reduce adipose tissue also improving fluid drainage. The supply of protein 

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supplements along with physical exercise seeks to increase muscle mass and reverse 
the underlying flaccidity, while improving microcirculation and mobilizing fat deposits. 
The treatment is complemented by the application of a cosmetic cream whose 
components contribute to reduce lipogenesis and improve circulation.5.   
This study is aimed at evaluating the degree of benefit obtained through this new 
multidisciplinary anti-cellulite treatment, semi-objectively, from the changes observed in 
the dermis structure and the subcutaneous tissue by means of skin ultrasound6, as well 
as the visual changes on skin appearance in the areas involved.  
 
5 STUDY OBJECTIVES 
5.1 Primary objective  
To evaluate the structural changes (trabecular texture) in subcutaneous tissue detected 
by skin ultrasound in patients with cellulite after a multidisciplinary treatment that 
includes diet, physical exercise and cosmetic cream. 
 
5.2 Secondary objectives 
 
To evaluate changes in skin thickness assessed by skin ultrasound after 
multidisciplinary treatment. 
 
To evaluate the changes in cellulite severity in the involved areas after the 
multidisciplinary treatment from photographic images. 
   
6 STUDY DESIGN  
6.1 Type of study 
A pilot, prospective, single blind, no controlled study with ultrasound evaluation of skin 
in patients undergoing treatment with a multidisciplinary program that includes diet, 
physical exercise and cosmetic cream.  .     
6.2 Randomization process 
Not applicable 
 
6.3 Type of control 
Not applicable.  
 
 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
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6.4 Masking Techniques 
Both the ultrasound images and the photographic images will be blindly assessed by 
two independent researchers, who will not know the identity of the patients evaluated.      
7 SUBJECT SELECTION 
7.1 Study population 
Women with non-infectious skin cellulite (edematous fibrosclerotic panniculopathy), 
submitted to the PnKCelulitis® multidisciplinary treatment program including diet, 
physical exercise and cosmetic cream. 
 
7.2 Inclusion criteria 
 
Women aged over 18 
 
Women who, regardless of their inclusion in this study, will undergo the anti-
cellulite multidisciplinary treatment program (PnKCelulitis® program) 
 
Women who agree to participate and sign the Informed Consent 
 
7.3 Exclusion criteria 
 
Pregnant or lactating women.  
 
Women in whom the ketogenic diet is contraindicated and therefore they cannot 
be on the multidisciplinary program's diet. These contraindications include:  
o Eating disorders, alcoholism, and/or drug addiction.  
o Severe psychological disorders (eg schizophrenia, bipolar disorder, 
depression ...). 
o Treatment with dicumarinic anticoagulants (Sintrom®) or cortisone. 
o Liver failure. 
o Severe kidney failure (gfr <30). 
o Type 1, and type 2 Diabetes mellitus if insulin dependent. 
o Hemopathies. 
o Cancer. 
o Cardiovascular or cerebrovascular diseases. 
o Acute attack of gout. 
o Nephrolithiasis verified by ultrasound. 
o Cholelithiasis verified by ultrasound.  
o Electrolyte imbalance, according to medical criteria.  
o Orthostatic hypotension.  
 
 
 

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7.4 Number of subjects 
The number of subjects expected for this pilot study is 30 women. 
7.5 Rationale of sample size 
In an exploratory pilot study to test a concept, it has been estimated that 30 patients 
will be sufficient to analyze results.  
Being a pilot study, it is understood that the estimation of the sample size is not 
necessary.  
7.6 Recruitment period 
We expect a 1-month recruitment period   
7.7 Criteria for withdrawal or dropouts 
Dropouts are those women who do not comply with the treatment schedule or do not 
complete treatment time established in the protocol of the multidisciplinary program.  
 
8 TREATMENT DESCRIPTION      
Multidisciplinary program for the treatment of cellulite  
The PnKCelulitis® Program consists of a multidisciplinary program that includes diet, 
protein supplements, physical exercise and anti-cellulite cream. Its duration depends 
on the degree of cellulite and is structured in 3 parts called "processes" (restructuring 
process, drainage process and toning process). Each of them consists of:  
 
Dietary regimen. The dietary regimen during the first part of the program 
(restructuring process 1 and 2) consists of a ketogenic low calorie diet (800-1200 
kcal/day) based on protein, and vitamin and trace element supplement intake. 
The dietary regimen during the drainage and toning processes is based on a 
non-ketogenic low calorie diet (1,200 - 1,500 kcal/day) accompanied by protein 
products and vitamin and trace element supplements.  
 
Physical exercise. Toning exercises that increase in difficulty and intensity in 
each process.  
 
Application of a cosmetic cream. It is a cosmetic cream consisting of: red 
coralline algae, caffeine, red vine L-carnitine, and phosphatidylcholine. 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
after a multidisciplinary  anti-cellulite treatment (PnKcelulitis program). PNKCELULITIS Study  
 
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According to the PnKCelulitis® program, the duration of the multidisciplinary treatment 
will vary between 61 days and 110 days, depending on the degree of cellulite assessed 
by the doctor who prescribes said treatment, according to the following scheme:  
 
  
Restructuring  
Drainage 
Toning 
1 
2 
GRADE 1 
7 days 
14 days 
20 days 
20 days 
GRADE 2 
14 days 
7 days 
30 days 
30 days 
GRADE 3 
20 days 
20 days 
40 days 
30 days 
 
Multidisciplinary treatment will be prescribed and controlled independently of this study 
by the prescribing physician as well as by the physical trainer and a team of dietitians 
from the Pronokal Group® Center. The doctor will be in charge to refer the patients to 
the Dermatology Service of the Santa Creu i Sant Pau Hospital to propose their 
participation.  
 
9 STUDY MEASUREMENTS AND ENDPOINTS 
9.1 Study endpoints 
9.1.1 Primary endpoint 
Differences in trabecular structure of subcutaneous tissue between the time prior to the 
multidisciplinary treatment and after the end of the treatment, assessed by skin 
ultrasound:  
  Indented subcutaneous fascicles in the dermis (length: measured from the 
center of the base to the point of maximum indentation in the dermis) 
9.1.2 Secondary endpoints 
 Changes in other skin structural parameters between the time prior to the 
multidisciplinary treatment and after the end of said treatment, assessed by skin 
ultrasound:   
 Thickness of skin: thickness of dermis, thickness of epidermis and total 
thickness of the skin 
 Changes in the echogenicity of the dermis  
 Presence of dermal edema 
 Presence of nodules in the subcutaneous areolar tissue 
 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
after a multidisciplinary  anti-cellulite treatment (PnKcelulitis program). PNKCELULITIS Study  
 
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 Changes in cellulite severity in the areas involved, between the time prior to the 
multidisciplinary treatment and after the end of treatment, assessed from 
photographic images, using the validated photonumeric scale of Hexel et al. 7, which 
evaluates the following parameters:   
 Number of visible depressions (0 = none, 1 = 1 to 4; 2 = 5 to 9; 3 = 10 or more 
depressions) 
 Depth of depressions (0 = No depressions; 1 = superficial depressions, 2 = 
medium depth depressions, 3 = deep depressions) 
 Morphology of the epidermis (0 = flat, 1 = "orange skin" look; 2 = "cottage 
cheese" look; 3 = quilted look 
 Grade of laxity or sagging (0 = absence of laxity/sagging; 1 = slight; 2 = 
moderate; 3 = severe) 
 Severity in accordance with Nürnberger and Muller scale(0 = zero grade; 1 = 
first grade; 2 = second grade; 3 = third grade) 
The addition of the scores obtained will provide a final score that will allow the 
cellulite classification:  
From 1 to 5 = mild cellulite 
From 6 to 10 = moderate cellulite 
From 11 to 15 = severe cellulite 
 
9.2 Study plan and procedures 
9.2.1 Recruitment of patients 
Patients will be referred to the Dermatology Department of Hospital de la Santa Creu i 
Sant Pau, from the PronoKal Group® Center by the doctor who prescribes it regularly.  
During the consultation, the dermatologist will explain the study to the patient and 
propose their participation. The patient will be provided with the information sheet and 
will be asked to sign the informed consent.  
9.2.2 Follow-up of patients 
Patient follow-up will be 10 ± 1 weeks to18 ± 1 weeks, depending on duration of 
treatment depending on the degree of cellulite.   
Only two controls will be performed: initial (prior to the multidisciplinary treatment) and 
final (after the end of the multidisciplinary treatment).   
 
 

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
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Initial visit 
The inclusion and exclusion criteria will be assessed and the signed informed consent 
will be obtained. Demographic data (age) are recorded and the degree of cellulite is 
evaluated following the Nürnberger and Muller scale (0 = zero grade, 1 = first grade, 2 
= second grade, 3 = third grade). The dermatologist will perform skin ultrasound and 
will take pictures. 
Final visit 
The dermatologist evaluations will be repeated: evaluation of the cellulite grade, 
accomplishment of skin ultrasound and photographic images.  
 
9.2.3 Procedure for taking photographs 
Photographs of the gluteal area (posterior) and hips (right and left), with the patient 
standing upright, 50 cm apart using a tripod, with an amplitude of focus from the iliac 
crest to the knee, always in the same place and the same lighting conditions.  
Patients should wear disposable paper underwear, exposing the largest possible 
gluteal surface. Photographs will not include tattoos or other types of marks that 
identify the patient. Digital images will be saved and identified with the patient code.  
The images will be assessed subsequently using the validated photonumeric scale, by 
two independent evaluators, blindly, that is, with a new coding that prevents them from 
identifying the patient or the visit to which it corresponds. The final result will be the 
average between both evaluations.      
 
9.2.4 Procedure for the assessment of skin ultrasound 
Ultrasound changes will be assessed at the end of the study. The ultrasound images 
will be saved with the patient and the visit code. At the end of the study, ultrasound 
changes will be assessed by two evaluators, independently and blindly. The final result 
will be the average between both evaluations.  
The parameters to be controlled are:  
• 
Dermis thickness 
• 
Hypodermis thickness 
• 
Total skin thickness 
• 
Dermis echogenicity 
• 
Assess presence of dermal edema 
• 
Presence of nodules in areolar subcutaneous tissue 

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• 
Indented subcutaneous fascicles in the dermis (length: measured from the 
center of the base to the point of maximum indentation in dermis) 
• 
Presence and quantity of perpendicular fibrous septa 
 
10 STATISTICAL ANALYSIS 
10.1 Descriptive statistics 
Descriptive statistic of all the variables collected in the Data Collection Notebook, with 
frequency tables for nominal variables and measures of central tendency and 
dispersion for the continuous variables. 95% confidence intervals (95% CI) will be 
estimated for the latter.  
10.2 Analysis of objectives 
For the analysis of the primary objective, we will study the mean values of the 
trabecular structure and skin thickness, comparing the results before and after 
treatment. Similarly we will compare the scores of the photographic images (overall 
score and scores of each scale). Qualitative variables will be compared using Fisher's 
exact test, and the quantitative variables will be compared by means of the student's t 
test (in the case of 2 groups) or by the one-way ANOVA test (for 3 or more groups). If 
the conditions of the Student t test or the Anova test are not met, we will use the non-
parametric test of the Mann-Withney U (2 groups) or the Kruskall-Wallis test (for 3 or 
more groups).  
For all tests, the significance level will be set at p <0.05.  
 
10.3 Responsibility for statistical analysis 
The CRO responsible for the statistical analysis of data will be:  
CROSSDATA – Punta Alta 
Enric Granados 145, 2º-1º 
08008Barcelona  
Tel.: +34 935 177 609. 
 
11 REPORT OF ADVERSE EVENTS 
The clinical evaluation of the subjects and safety of the multidisciplinary treatment is 
not the purpose of this study. Patients will only be visited before and after treatment. 
Therefore, no intermediate control will be performed to assess the safety and 
tolerability of the multidisciplinary anti-cellulite treatment during its application. 
However, if patients report any adverse effects to the anti-cellulite treatment, the doctor 
will record it in the Data Collection Notebook, specifying:  
 
Type of reaction  

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 
Intensity: mild (no limitation of daily living activities, patient may have mild 
discomfort), moderate (cause some limitation of daily living activities, patient 
may experience increased discomfort), severe (inability to perform daily living 
activities; patient may report intolerable pain or discomfort). 
 
Duration  
 
Causality with the DHA dietary supplement treatment under study: definitive, 
likely, possible, unlikely, unrelated, unknown. 
 
Therapy administered 
 
Resolution 
 
If a subject reports a serious adverse event (see sidebar) during the time of this study, 
the physician should gather all available data and report them immediately (if possible 
within 24h.) by fax, telephone or e-mail to the Sponsor, who will implement the 
established Pharmacovigilance procedures in accordance with current legislation.  
 
 
 
Sponsor:  
Dr. Ignacio Sajoux 
PronoKal Group Medical Director 
Roger de Llúria 58 
08009 Barcelona 
Tel. +34 666 98 80 21 
Fax : +34 931 833 310 
 
12 ETHICAL ISSUES 
12.1 General considerations 
This study will be conducted in accordance with current regulations, international 
accepted ethical standards of Good Clinical Practice (CPMP/ICH/135/95) and the 
principles established in the latest version of the Declaration of Helsinki. 
SERIOUS ADVERSE REACTION: is any adverse reaction that can be classified in one or 
more of the following categories: 
- 
Lethal 
- 
Life threatening 
- 
It causes significant or persistent discapacity/ disability 
- 
It causes hospitalization or prolongs hospitalization 
Congenital anomalies/birth defects and serious adverse clinical consequences associated 
with use under conditions other than those set out in the Summary of Product Characteristics 
(SPC), overdose or abuse are also included. 
Medical judgment should be applied when deciding whether an event or reaction is serious in 
other situations. Major adverse reactions or events that do not pose immediate threat to life, 
or do not cause death or hospitalization but may endanger the patient, should be deemed 
serious. 
 

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12.2 Evaluation by an Authorized Clinical Research Ethics Committee 
Prior to its initiation, this study will be submitted to the Clinical Research Ethics 
Committee (CREC) of the Foundation of Health Management of the Santa Creu i Sant 
Pau Hospital to obtain its approval. 
12.3 Patient information and informed  consent  
The patient will be informed about the study issues for their knowledge and written 
informed consent will be requested for participation in the study (Attachments 2 and 3). 
 
12.4 Data confidentiality  
Patient's identity in the study forms and in the digital files of the ultrasound and 
photographic images will be coded. The investigating physician will maintain a separate 
confidential record linking the identification codes with the patients' names.   
  
13 PRACTICAL CONSIDERATIONS 
13.1 Workplan 
The principal investigator will be in charge of including the patients referred to his 
office. Once the patient has read the Patient Information Sheet (Attachment 2) and 
confirmed their willingness to participate, the investigator will obtain the signature of the 
Informed Consent Form (Attachment 3) and must keep them with the rest of the 
documentation of every subject.  
The doctor will record the data requested in the CRD and will perform the skin 
ultrasound and the taking of photographs. The ultrasound images will be saved 
digitally, identified by the patient and the visit code; and will be saved to be evaluated 
at the end of the study, blindly, by the principal investigator and by another evaluator 
separately. Similarly, the photographs will be saved in digital files identified with the 
patient and visit code. The latter will be recoded before evaluation by two independent 
evaluators to ensure the blindness of the patient and the visit in which the photographs 
were taken.  
The investigator will not perform any clinical follow-up of the patients during the 
multidisciplinary medical treatment and will only visit the patients prior to and after the 
anti-cellulite program.  
 
13.2 Monitoring  
CROSSDATA (CRO) will carry out remote monitoring of all patients, with follow-up 
reports of all of the study visits. If necessary, there will be on-site monitoring visits at 
the center.  

Pilot study for ultrasound evaluation of structural changes in subcutaneous tissue in patients with cellulite 
after a multidisciplinary  anti-cellulite treatment (PnKcelulitis program). PNKCELULITIS Study  
 
PNK-CEL-2016-06 Version 1.0 dated 05 May, 2016 
18 
 
13.3 Financing the study 
The Sponsor will be in charge of the study expenses.  
 
13.4 Disseminating the study results 
The overall data will be used by the whole project, not individually.  
With the results obtained, we will issue the final study report, which will be deemed 
confidential.  
With the overall data we will try to maximize the exploitation of the study results in the 
form of publications or reports in conferences, always mentioning the study.  
 
14 REFERENCES 
                                                 
1 Khan, M.H., Victor, F., Rao, B., Sadick, N.S. Treatment of cellulite: part I. Pathophysiology. J 
Am Acad Dermatol. 2010;62:361–370. 
2 Rawlings AV. Cellulite and its treatment. Int J Cos Sci 2006;28:175-190. 
3 Rossi AM, Katz BE. A modern approach to the treatment of cellulite. Dermatol Clin. 2014 
Jan;32(1):51-59. 
4 Leszko M. Cellulite in menopause. Prz Menopauzalny. 2014 Oct;13(5):298-304.  
5 http://www.pronokalgroup.com/es/pnkcelulitis/ 
6 Mlosek RK, Dębowska RM, Lewandowski M, Malinowska S, Nowicki A, Eris I. Imaging of the 
skin and subcutaneous tissue using classical and high-frequency ultrasonographies in anti-
cellulite therapy. Skin Res Technol. 2011;17(4):461-8. 
7 Hexsel DM, Dal'forno T, Hexsel CL. A validated photonumeric cellulite severity scale. J Eur 
Acad Dermatol Venereol. 2009;23(5):523-8.