Apparatus and method for evaluating and treating cellulite

Abstract

To provide an apparatus and method for evaluating and treating cellulite. [Solution] A verified photometric scale for assessing the severity of cellulite in a human subject's affected area, Images of the affected area of ​​a real patient, comprising 3 to 10 points, organized into different categories representing the level of severity based on the characteristics of cellulite, The aforementioned features are selected from the group consisting of the number, depth, size, width, diameter, and distribution of the indentations, and A photodigital scale in which, when used by multiple users, at least 40% assign the areas of cellulite in question to the same severity level.

Description

Technical Field

[0001] Related Applications This application claims priority to U.S. Provisional Application No. 62 / 465,622, filed Mar. 1, 2017; U.S. Provisional Application No. 62 / 485,705, filed Apr. 14, 2017; and U.S. Provisional Application No. 62 / 607,188, filed Dec. 18, 2017, the entireties of which are incorporated herein by reference to the fullest extent permitted by law.

[0002] The present invention relates to the field of evaluation and treatment of edematous fibrosclerotic panniculopathy (EFP or cellulite).

Background Art

[0003] Edematous fibrosclerotic panniculopathy (EFP), commonly known as cellulite, is defined as a local metabolic disorder of subcutaneous tissue that results in abnormal skin topography. The condition presents as dimpled skin, particularly in the buttock-thigh region. EFP is caused by herniation of subcutaneous fat lobules through the skin-subcutaneous tissue junction and / or shortening of the collagen septa that traverse the subcutaneous tissue layer and connect the dermis to the underlying fascia. This creates a non-flat surface with dimples. EFP is a medical condition that potentially results in cosmetically unacceptable skin alterations and affects an estimated 85% to 98% of post-pubertal women.

[0004] The pathophysiology of EFP is not fully understood, but there are three main theories: edema resulting from excessive hydrophilicity of the intracellular matrix, changes in local microcirculation, and an anatomical structure of the collagenous subcutaneous tissue that is different in women compared to men.

[0005] EFP is known to be distinct from generalized obesity. In generalized obesity, adipocytes undergo hypertrophy and hyperplasia that are not limited to the pelvis, thighs, and abdomen. Within the EFP region, adipocytes have different physiological and biochemical characteristics from adipose tissue located in other regions. Large, metabolically stable adipocytes characterize the EFP-prone region, and their responsiveness to catecholamine-induced lipolysis is lower within EFP tissue compared to visceral fat, which is the most responsive.

[0006] Subcutaneous fat lobes are separated from each other by thin, usually rigid, collagenous connective tissue strands that traverse the fat layer and connect the dermis to the underlying fascia. These septa stabilize the subcutaneous tissue and divide the fat. In EFP, shortening of the collagenous septa due to fibrosis induces contraction at the insertion points of the trabecular meshwork, causing the depressions that characterize EFP. The percentage of thinner, vertical subcutaneous tissue septa is higher in women with EFP than in men. Weight gain makes EFP more prominent, but EFP can also be present in lean individuals. Genetics may also play a role, as EFP tends to be familial.

[0007] While there are treatments used as attempts to treat cellulite, there are no approved pharmacological procedures. Despite the existence of multiple treatment modalities, there is little scientific evidence that any of these procedures are beneficial. In fact, much of the evidence is anecdotal, subjective, or based solely on patient self-assessment. Some of the historical treatments for EFP include weight loss, topical medications, massage, liposuction, mesotherapy, radiofrequency, subcision and electrodermal subcision, and Laser treatment is one example, and some of these procedures may carry an increased risk of adverse effects.

[0008] There remains an unmet need for safe and effective treatments to improve the aesthetic outcomes of women with cellulite. To effectively treat cellulite, treatment approaches may require the disruption of skin septa, which are composed of collagen and are the cause of the troublesome skin depressions for many women.

[0009] XIAFLEX® (collagenase Clostridium histolyticum, or CCH, or EN3835) is a biologic approved in the United States, the EU, Canada, Australia, and Japan for the treatment of adult Dupuytren's contracture (DC) patients with palpable contracture cords, and in the United States and the EU for the treatment of adult males with Peyronie's disease (PD) with palpable plaques and penile curvature of at least 30 degrees at the start of treatment. XIAFLEX® (also known as XIAPEX in Europe) contains a combination of two subtypes of collagenase derived from Clostridium histolyticum. These collagenase subtypes are thought to work synergistically together to cleave the bonds in collagen structures. In a previous dose-finding study in 150 women with EFPs in the posterolateral thigh or buttocks, up to three injections of 0.84 mg of CCH demonstrated a significant improvement in EFP appearance compared to placebo (P<0.05). Non-patent document 1.

[0010] Treatment outcomes may be assessed by the physician and / or the patient. To that end, the U.S. Food and Drug Administration (FDA) has published industry guidance: Non-Patent Document 2. This guidance explains how the FDA considers and evaluates existing, modified, or newly created patient-reported outcome devices used to support claims in approved medical product claims.

[0011] The appearance of cellulite has been assessed in numerous ways using various photometric and other scales. Such scales include the Hexsel Cellulite Severity Scale ("Hexsel CSS") and the Global Aesthetic Improvement Scale ("GAIS"). The Hexsel CSS is described in Non-Patent Document 3. Briefly, the Hexsel CSS scores a patient across five clinical morphological features of cellulite: (A) the number of visible depressions; (B) the depth of the depressions; (C) the morphological appearance of the skin surface alteration; (D) the grade of flabbiness, skin looseness, or ptosis; and (E) the classification scale first described by Nurnberger and Muller (Non-Patent Document 4). Twenty separate photographs (i.e., four for each of the five morphological features) are used to grade the severity of each item from 0 to 3, and these are added together to obtain a final total score in the numerical range of 0 to 15. Based on the final numerical score, cellulite was further classified as mild, moderate, or severe.

[0012] While the Hexsel CSS has been reported to be reliable and consistent when used to assess cellulite on the buttocks and posterior thighs, which are considered collectively, "the grades of laxity, skin looseness, or ptosis do not positively contribute to the scale's final consistency." (Non-Patent Document 5). Furthermore, the Hexsel CSS does not provide a concise means of assessing the severity of cellulite due to the number of steps required. The Hexsel CSS is complex and relies on users to sum the results of multiple subcategories to arrive at a final score.

[0013] GAIS assesses the global aesthetic improvement in appearance compared to before treatment, based on the judgment of researchers. It is a 5-point scale. Generally, the rating categories are unbalanced, including "worsening," "no change," "improvement," "significant improvement," and "very significant improvement." [Prior art documents] [Non-patent literature]

[0014] [Non-Patent Document 1] Goldman MP,et al.J AM ACAD DERMATOL.2015;72(5 Suppl).Abstract 1721 [Non-Patent Document 2] Patient-Reported Outcome Measures:Use in Medical Product Development to Support Labeling Claims(2009) [Non-Patent Document 3] Hexsel et al., “A Validated Photonumeric Cellulite Severity Scale,” J.EUR.ACAD.DERMATOL.Venereol.2009 May;23(5):523-8 [Non-Patent Document 4] Nurnberger et al., “So-called Cellulite: An Invented Disease” J.DERMATOL.SURG.ONCOL.1978;4:221-229 [Non-Patent Document 5] Almeida et al., “Intra- and inter-observer reliability of the application of the cellulite severity scale to a Spanish female population” J.EUR.ACAD.DERMATOL.VENEREOL.,2013 June;27(6):694-8 [Overview of the Initiative] [Problems that the invention aims to solve]

[0015] Therefore, these scales in the prior art have numerous shortcomings, including a lack of accuracy between physicians and patients. Consequently, there is a need in the art for a reliable and consistent method for assessing, quantifying, and rating the nature and degree of cellulite. [Means for solving the problem]

[0016] This disclosure satisfies the above needs and relates to a novel, validated scale useful for the diagnosis, assessment, and treatment of cellulite. The disclosure further relates to a method for treating cellulite, specifically, to administering a therapeutically effective dose of collagenase obtained from or derived from Clostridium histolyticum, such as XIAFLEX®, to a subject in need of cellulite treatment, and then assessing the degree of improvement using the novel scale. The scale of this disclosure can be used with any therapeutic agent or treatment for cellulite to (a) establish a baseline before treatment, (b) assess progress during treatment, or (c) evaluate the therapeutic effect after treatment.

[0017] In one embodiment, the Disclosure provides a series of 3 to 15 photographs, illustrations, figures, computer images, 3D models, MRI images, thermograms, ultrasound images, or similar, each having a different cellulite severity rating or level. The scale is used by physicians / clinicians and patients. The effectiveness of a particular collagenase treatment described herein may be based on a composite endpoint including clinician and patient ratings, where improvement is shown on both scales for the same subject, i.e., a pre-specified level of improvement is demonstrated on both the clinician and patient scales.

[0018] In another embodiment, the Disclosure relates to a scale for assessing the severity of cellulite in the buttocks or thighs of a human subject, comprising 3 to 10 points representing the area of ​​the human buttocks or thighs. A photograph, illustration, model, image, or diagram that is organized into different categories representative of severity levels based on the characteristics of cellulite, includes a photograph, illustration, model, image, or diagram, where the characteristics are selected from the group consisting of the number and depth of dimples, and when the scale is used by a plurality of clinicians, at least 40% of the clinicians assign the cellulite area of the subject to the same severity. In certain embodiments, the clinicians provide the same severity level in at least 50%, or at least 60%, or at least 70%, or at least 80%, or at least 90%, or approximately 100% of the patients.

[0019] In another aspect, a scale and method for performing a clinical assessment of a patient are provided, including a baseline assessment by applying the scale of the present invention. The scale may include a row or column of photographs corresponding to different severity categories. For example, the scale may include labels and word-based descriptions associated with a row of photographs corresponding to different severity categories. The word-based descriptions or labels may include the words NONE, ALMOST NONE, MILD, MODERATE, and SEVERE. After such words, descriptive words are shown that describe one or more characteristics commonly found in the row of photographs indicating the severity category.

[0020] In a further embodiment, the present disclosure is validated against a 5-point photographic quantification scale, such as the Clinician Reported Photonumeric Cellulite Severity Scale (CR-PCSS) and the Patient Reported Photonumeric Cellulite Severity Scale (PR-PCSS). See FIGS. 2A-2E, FIGS. 3A-3E, FIGS. 4A-4E, FIGS. 5A-5E. These photographic quantification scales are designed to quantify cellulite severity into five levels. These validated CR-PCSS and PR-PCSS scales are particularly suitable for (a) establishing a baseline before treatment, (b) assessing progress during treatment, or (c) evaluating treatment efficacy after treatment.

[0021] When using the scale, a clinician or patient matches the patient's cellulite condition to one of the severity levels on the CR-PCSS (see FIGS. 3 and 5 for the clinician) or PR-PCSS (see FIGS. 2 and 4 for the patient) by comparing one quadrant of the patient (left buttock, right buttock, left posterior lateral thigh, or right posterior lateral thigh), also known as the treatment area, to the pictures, labels, and descriptors on the CR-PCSS or PR-PCSS. The five severity levels are none, almost none, mild, moderate, and severe. Separate scales are designed for the buttock evaluation and the thigh evaluation, both using the same 5-point severity levels but with different descriptions tailored to each area.

[0022] Also disclosed is a method for assessing the severity of cellulite in human subjects, comprising: (a) selecting an affected area of ​​the thigh or buttocks to be evaluated; (b) comparing the affected area of ​​the thigh or buttocks with a series of photographs, each having a corresponding number as shown in Figures 2-5; (c) identifying the photograph that most closely resembles the appearance of the affected area of ​​the thigh or buttocks; (d) reading the number corresponding to the identified photograph; and (e) identifying the label that most closely fits the thigh or buttocks or the affected area of ​​the thigh or buttocks, wherein the use of the scale ensures consistency among at least 50% of evaluators.

[0023] In some embodiments, when the method using the CR-PCSS scale is used by multiple clinicians, at least 40% of those clinicians use the following method for areas of cellulite in patients: The same cellulite severity rating is given to the patient when they are screened and from day 1 before treatment. Alternatively, in another embodiment, the clinician provides such the same rating to about 50%, or about 60%, or about 70%, or about 80%, or about 90%, or about 100% of the patients.

[0024] Also disclosed is a method for treating or alleviating cellulite in a patient requiring treatment or alleviation of cellulite, comprising: (a) establishing a baseline by assessing the severity of the patient's cellulite using one or more validated scales; (b) injecting a therapeutically effective dose of CCH into the affected area of ​​the patient's thigh or buttocks; and (c) evaluating the improvement resulting from such injection using the one or more validated scales.

[0025] In one embodiment, the amount of CCH injected is approximately 0.01 mg to 2 mg per treatment session in one or more injections. Any suitable collagenase composition may be used in the present invention. One to eight treatment sessions may be performed, occurring approximately every 10 to 60 days.

[0026] In another embodiment, patients receiving collagenase treatment have an improvement of 2 points or more from baseline in both CR-PCSS and PR-PCSS at approximately 71 days post-treatment, or an improvement of 1 point or more from baseline in both CR-PCSS and PR-PCSS at approximately 71 days post-treatment. Such patients have an improvement of 2 points or more from baseline in both CR-PCSS and PR-PCSS at approximately 6 months post-treatment, or an improvement of 1 point or more from baseline in both CR-PCSS and PR-PCSS at approximately 6 months post-treatment, or an improvement of 2 points or more from baseline in both CR-PCSS and PR-PCSS at approximately 12 months post-treatment, or an improvement of 1 point or more from baseline in both CR-PCSS and PR-PCSS at approximately 12 months post-treatment. Furthermore, such patients have an improvement of 2 points or more or 1 point or more from baseline in both CR-PCSS and PR-PCSS at approximately 22, 43, 90, or 180 days post-treatment.

[0027] In some embodiments, patients show an improvement of 3 points or more from baseline in both CR-PCSS and PR-PCSS scores approximately 6 months after treatment, or have an improvement of 3 points or more from baseline in both CR-PCSS and PR-PCSS scores approximately 12 months after treatment, or have an improvement of 3 points or more from baseline in both CR-PCSS and PR-PCSS scores approximately 12 months after treatment. Furthermore, such patients have an improvement of 3 points or more from baseline in both CR-PCSS and PR-PCSS scores approximately 22, 43, 90, or 180 days after treatment. In another embodiment, collagenase treatment exhibits persistence (as defined herein).

[0028] Additional embodiments of this scale, method, and similar will become apparent from the following description, drawings, examples, and claims. As can be understood from the preceding and subsequent descriptions, any feature described herein, and any combination of two or more such features, is included within the scope of this disclosure, provided that the features included in such combination are not mutually inconsistent. In addition, any feature or combination of features may be specifically excluded from any embodiment or aspect. Additional aspects and embodiments are described in the subsequent description and claims, particularly when considered in conjunction with the accompanying examples and drawings.

[0029] This patent or application file includes at least one color drawing. Copies of this patent or the published patent application, including color drawings, are available from the Patent and Trademark Office upon request and payment of the necessary fees.

[0030] The features of the aforementioned embodiments will be more readily understood by referring to the accompanying drawings and the embodiments for carrying out the subsequent invention. A description of the drawings is as follows.

[0031] In other words, the gist of this invention relates to the following: Item 1 A validated photometric scale for assessing the severity of cellulite in affected areas of human subjects, Images of the affected area of ​​a real patient, comprising 3 to 10 points, organized into different categories representing the level of severity based on the characteristics of cellulite, The aforementioned features are selected from the group consisting of the number, depth, size, width, diameter, and distribution of the indentations, and A photodigital scale in which, when used by multiple users, at least 40% assign the areas of cellulite in question to the same severity level. [Effects of the Invention]

[0032] The present invention may provide an apparatus and method for evaluating and treating cellulite. [Brief explanation of the drawing]

[0033] [Figure 1] This is an illustration of the anatomical structure of cellulite. [Figure 2] This is a series of photographs showing PR-PCSS on the thigh. [Figure 3] These are a series of photographs showing CR-PCSS on the thigh. [Figure 4] This is a series of photographs showing PR-PCSS for the buttocks. [Figure 5] This is a series of photographs showing CR-PCSS on the buttocks. [Figure 6] These are a series of photographs showing cellulite in the buttocks of two patients, one treated with CCH and the other with placebo, respectively, indicating either a 2-point improvement in the CR-PCSS and PR-PCSS ratings, or no change in the ratings. [Figure 7] This is an illustration of an injection technique useful for administering CCH or placebo to cellulite depressions. [Figure 8] This is a schematic diagram of the research design. [Figure 9] This graph reports the composite response of the primary and secondary endpoints at day 71 after CCH or placebo treatment. [Figure 10] This is a series of photographs showing before and after cellulite treatment in the buttocks of a patient treated with CCH, exhibiting a composite response of 2 points from baseline assessment. [Figure 11] This is a series of photographs showing before and after cellulite treatment in the buttocks of a patient treated with CCH, exhibiting a 1-point composite response from baseline assessment. [Figure 12] This is a series of photographs showing before and after cellulite treatment on the buttocks of a patient treated with CCH, exhibiting a 1-point response based on PR-PCSS. [Figure 13]These are a series of photographs showing the before and after results of cellulite treatment on the buttocks of patients who were treated with a placebo and showed no change with either CR-PCSS or PR-PCSS. [Figure 14] This bar graph shows the probability distribution of changes in CR-PCSS from baseline to day 71 for each treatment group, based on all available data from the Phase 2b study. [Figure 15] This bar graph shows the cumulative distribution function (CDF) of the change in CR-PCSS from baseline to day 71 for each treatment group, based on all available data from the Phase 2b study. [Figure 16] This bar graph shows the probability distribution of changes in PR-PCSS from baseline to day 71 for each treatment group, based on all available data from the Phase 2b study. [Figure 17] This bar graph shows the cumulative distribution function (CDF) of the change in PR-PCSS from baseline to day 71 for each treatment group, based on all available data from the Phase 2b study.

[0034] This application file includes at least one color drawing. Copies of this patent application publication with color drawings will be provided to third parties by the Patent and Trademark Office upon request and payment of the necessary fees. [Modes for carrying out the invention]

[0035] Various aspects and embodiments are described in detail herein. However, these aspects and embodiments can be embodied in numerous different forms and should not be construed as limiting; these embodiments are provided to make this disclosure thorough and complete and to adequately communicate the scope of the subject matter of the invention to those skilled in the art. Whether described above or below, all publications, patents, and patent applications referenced herein are incorporated herein by reference in their entirety.

[0036] A.Definition Unless otherwise defined, all terms and expressions used herein include the meanings they have acquired in the art unless it is clearly shown otherwise or the opposite is obvious from the context in which the term or phrase is used. Any methods and materials similar to or equivalent to those described herein may be used in carrying out or testing the present invention, but specific methods and materials are described herein.

[0037] Unless otherwise stated, the use of individual numerical values ​​is given as approximate, as if preceded by the word "about" or "approximately." Similarly, numerical values ​​within the various ranges specified in this application are given as approximate, as if preceded by the word "about" or "approximately," as if preceded by the minimum and maximum values ​​within the specified range, unless otherwise specified. In this style, variations above and below the specified range can also be used to achieve substantially the same results as values ​​within the range. Where used herein, the terms "about" and "approximately" have the plain and ordinary meanings to a person skilled in the art when referring to numerical values, in the art most closely relating to the subject matter of this disclosure, or to the art relating to the scope or element being covered. The amount extending beyond the strict numerical boundary depends on a number of factors. Some of the factors that may be considered include, for example, the criticality of the element and / or the effect of variations of a given quantity on the performance of the claimed subject matter, as well as other considerations known to a person skilled in the art. Where used herein, the use of different amounts of significant figures for different numbers is not intended to limit how the use of the words “about” or “approximately” works to broaden a particular number or range. Therefore, as a general rule, “about” or “approximately” broadens the range of a number. Furthermore, the disclosure of a range is also intended as a continuous range, including all values ​​between the minimum and maximum values, as well as the broadening of the range brought about by the use of the terms “about” or “approximately.” Consequently, the description of value ranges herein is simply intended to serve as a concise way of referring individually to each individual value that falls within the range, and each individual value is incorporated herein as if it were described individually.

[0038] As used herein, “affected area” means a quarter (as defined below) or other area of ​​cellulite that will be treated with CCH or any other therapeutic agent or treatment for cellulite.

[0039] As used herein, the "Clinical Reported Photoquantified Cellulite Severity Scale" (CR-PCSS) refers to the photoquantified scale shown in Figures 3A–3E and 5A–5E, which is used by physicians / clinicians and is designed to quantify cellulite severity into five levels.

[0040] As used herein, “composite responder” means a patient in whom cellulite severity has improved by at least two levels in both PR-PCSS and CR-PCSS.

[0041] As used herein, “persistence” means 1) from the date of the visit in which the subject became a composite responder at level 2 to the first of two consecutive visits in which the assessment rating has been returned and is maintained at the baseline rating, and 2) from the date of the visit in which the subject became a composite responder at level 1 to the first of two consecutive visits in which the assessment rating has been returned and is maintained at the baseline rating.

[0042] As used herein, “image” means a photograph, illustration, diagram, model, 3D model, computer-generated image, MRI image, and similar.

[0043] "Optional" or "by optional choice" means that the elements, components, or circumstances described thereafter may or may not occur, and as a result, this description includes both instances in which such elements, components, or circumstances occur and instances in which they do not.

[0044] As used herein, the "Patient-Reported Photoquantified Cellulite Severity Scale" (PR-PCSS) refers to the photoquantified scale shown in Figures 2A–2E and 4A–4E, which is designed to quantify cellulite severity into five levels.

[0045] As used herein, “photodigitization” means the use of a series of photographs, illustrations, diagrams, models, 3D models, computer-generated images, MRI images, images and the like, each assigned to a different level of cellulite severity on a given scale.

[0046] As used herein, “quadrant” means the left buttock, right buttock, left posterolateral thigh, or right posterolateral thigh of the patient.

[0047] The terms “subject” and “patient” are used interchangeably herein and refer to humans or other mammals.

[0048] As used herein, the term “therapeutic dose” refers to the amount of bioactive agent required to stimulate or initiate the desired beneficial outcome. The amount of bioactive agent used will be the amount required to deliver the amount of bioactive agent needed to achieve the desired outcome. In practice, this amount will vary widely depending on the specific bioactive agent being delivered, the site of delivery, and the pharmacokinetics of dissolution and release for delivery of the bioactive agent to the affected skin.

[0049] As used herein, the term “treatment session” means one or more injections or treatments to the affected area using at least one therapeutically effective amount of an active agent useful for treating cellulite in a single visit.

[0050] As used herein, the terms “validated,” “validity,” or “validation” mean the process by which a particular scale is demonstrated to be accurate and reliable. This includes the reproducibility of the visual assessment to ensure that the same results can be consistently obtained. Validation further verifies the precision, accuracy, and sensitivity of the scale to confirm that the measurements obtained using that scale are reliable, reproducible, and robust.

[0051] B. Introduction The invention of this disclosure satisfies the need for a reliable and consistent scale for effectively assessing cellulite, particularly for use in the treatment of cellulite. Such a scale is important for clinicians and patients in measuring the effectiveness of treatment. Thus, objective quantification is crucial for measuring the effectiveness of treatment by comparing the severity of cellulite before and after treatment.

[0052] C. Therapeutic agents useful in this disclosure This disclosure relates to the administration of collagenase obtained from or derived from Clostridium histolyticum (e.g., by recombinant means). The scales of this disclosure are used in combination with therapeutic agents for treating and evaluating cellulite. In one embodiment, there exists a method for treating or alleviating cellulite in a patient requiring treatment or alleviation of cellulite, comprising: (a) establishing a baseline by assessing the severity of the patient's cellulite using one or more validated photodigital scales; (b) injecting a pharmaceutical composition containing isolated and purified collagenase I and collagenase II, each having at least 95% accuracy, in a ratio of approximately 1:1, in an amount of about 0.01 mg to about 5 mg (based on the collagenase I / II components) into the affected area where cellulite is present; and (b) evaluating the improvement resulting from such injection using the one or more validated photodigital scales.

[0053] In one embodiment, the above-mentioned mixture of collagenases I and II may be injected in one or more injections at an amount of approximately 0.01 mg to 5 mg per treatment session, for example, this dose may be divided equally into approximately 3 to approximately 20 injections. The dose of the mixture in one or more injections may be approximately 0.1 mg to 1 mg, or 0.25 mg to 0.75 mg, or 0.1 mg to 2 mg, or 0.25 mg to 1.75 mg, or 0.5 mg to 1 mg, 0.1 mg to 3 mg, or 0.25 mg to 2.75 mg, or 0.5 mg to 2.5 mg, or 0.75 mg to 2.25 mg, or 1 mg to 2 mg, or 0.1 mg to 4 mg, or 0.25 mg to 3.75 mg, or 0.5 mg to 3.5 mg, or 0.75 mg to The dosage may include 3 mg, or 1 mg to 3 mg, or approximately 0.05 mg, 0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.5 mg, 0.6 mg, 0.7 mg, 0.8 mg, 0.9 mg, 1 mg, 1.1 mg, 1.2 mg, 1.3 mg, 1.4 mg, 1.5 mg, 1.6 mg, 1.7 mg, 1.8 mg, 1.9 mg, 2 mg, 2.25 mg, 2.5 mg, 2.75 mg, 3 mg, 3.25 mg, 3.5 mg, 3.75 mg, 4.0 mg, 4.25 mg, 4.5 mg, 4.75 mg, or 5 mg. In another embodiment, the dose administered is approximately 0.06 mg, 0.48 mg, 0.84 mg, or 1.68 mg in one or more injections. For example, approximately 0.06 mg, 0.48 mg, 0.84 mg, or 1.68 mg is administered in 12 injections.

[0054] The dose of the collagenase mixture described above can also be expressed in mg per injection, for example, approximately 0.001 mg to 0.5 mg per injection, approximately 0.01 mg to 5 mg per injection, or approximately 0.005 mg to 0.1 mg per injection, or 0.005 mg, 0.04 mg, or 0.07 mg per injection. The collagenase mixture may also take the form of a pharmaceutical preparation containing collagenase and pharmaceutically acceptable excipients.

[0055] For example, approximately 0.84 mg of the above collagenase mixture is equivalent to one treatment session in total. The collagenase mixture may be administered to the affected area every 15 to 25 days in 12 equally divided injections, each containing approximately 0.84 mg (i.e., 0.07 mg x 12 injections = 0.84 mg). Figure 7 shows an example of an injection technique useful for administering the collagenase mixture to cellulite depressions. In one embodiment, XIAFLEX® may be used as the collagenase preparation. Other potentially suitable collagenases are described in U.S. Patents 7,811,560, 9,757,435, 9,744,138, and WO2012 / 125948.

[0056] More specifically, various collagenase compositions having specific activities of approximately 10,000 ABC units / mg to approximately 25,000 ABC units / mg, or approximately 15,000 ABC units / mg, or approximately 17,500 ABC units / mg, or approximately 20,000 ABC units / mg, or approximately 22,500 ABC units / mg, or approximately 10,000 ABC units / 0.58 mg, or 17,241 ABC units / mg may be used, and "mg" refers to the amount of collagenase present in the composition (separate from excipients and other components). Therefore, the present invention intends to inject approximately 500 ABC units to approximately 50,000 ABC units per treatment session, or approximately 10,000 ABC units to approximately 25,000 ABC units per treatment session.

[0057] In another embodiment, the dose of collagenase per injection is approximately 50 ABC units to approximately 2,500 ABC units, or approximately 85 ABC units to approximately 2,000 ABC units, or approximately 150 ABC units to approximately 1,750 ABC units, or approximately 200 ABC units to approximately 1,500 ABC units, or approximately 300 ABC units to approximately 1,250 ABC units, or approximately 500 ABC units to approximately 1,000 ABC units.

[0058] The mixture of collagenase I and II is preferably used in a ratio of approximately 1:1, but other ratios, such as 0.1-2:1, or 0.25-2:1, or 0.5-2:1, or 0.75-2:1, or 1:0.1-2, or 1:0.25-2, or 1:0.5-2, or 1:0.75-2, may also be used. Each of collagenase I and II may have an area purity of at least 80%, 85%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100% as measured by reverse-phase HPLC.

[0059] The volume of collagenase composition to be injected may range from 0.01 mL to 3 mL per injection, or approximately 0.2 mL to 15 mL in total per treatment session.

[0060] Since the effectiveness of any treatment or procedure for cellulite can be measured by the scale disclosed herein, this disclosure is not limited to collagenases.

[0061] D. Scale used in the present invention 1. Explanation of scale This disclosure relates to a validated scale for visually characterizing the nature, extent, and severity of cellulite in human patients. The scale may include approximately 3 to 15 photographs, illustrations, figures, 3D models, computer images, MRI images, and similar images categorized by levels of cellulite severity. The scale may be patient-reported or physician-reported. The levels are matched by comparing one quarter of the patient (left buttock, right buttock, left posterolateral thigh, or right posterolateral thigh) to one of the scale's severity levels, thereby matching the patient's cellulite condition to one of the scale's severity levels. In one embodiment, the scale has 5, 6, 7, or 8 levels.

[0062] In one embodiment, the applicant found, among other things, that the validated 5-point photodigitization scales (CR-PCSS and PR-PCSS) were more reliable, repeatable, and less prone to error than known scales. Such scales yielded consistency of approximately 40%, 50%, 60%, 70%, or 80% or higher across a large number of raters who applied the scale to the same patient. Such intra-rater and inter-rater reliability represents a significant improvement over previously known scales.

[0063] The scales disclosed herein identify various cellulite features selected from the group consisting of the location, size, width, diameter, and number of indentations, the depth, shape, and distribution (spacing) of the indentations. In a particular embodiment, the feature is that the indentations are at least 1 cm deep and have a major axis of 2 cm or less.

[0064] In addition to the CR-PCSS and PR-PCSS, which are detailed in subsequent sections, several other scales may also be used in this disclosure. For example, such a scale is the Hexsel Cellulite Severity Scale (CSS), which consists of five clinical morphological features in cellulite, as shown in Table 1. [Table 1]

[0065] 2. CR-PCSS The Clinically Reported Photometric Cellulite Severity Scale (CR-PCSS) refers to the photometric scale shown in Figures 3A-3E and 5A-5E, used by physicians / clinicians to quantify cellulite severity into five levels. More specifically, the characteristics of each level in the CR-PCSS are as follows: a. CR-PCSS buttocks (Figures 5A-5E) i.CR-PCSS rating: 0 (none) • Skin appears smooth Even based on a thorough examination, there are no obvious depressions or ridges. ii. CR-PCSS rating: 1 (almost none) • A very small number of indentations / ridges • All dents are very shallow or superficial It is difficult to notice the indentation / ridge unless you look closely. iii. CR-PCSS rating: 2 (mild) • Several noticeable indentations / ridges Most dents are not considered to be very deep. Most of the buttocks have smooth skin, with indentations being scattered or concentrated in certain areas. iv.CR-PCSS rating: 3 (moderate) • Numerous prominent depressions / ridges, most of which are quite distinct. Some of the dents may be considered somewhat deep, but most are considered moderately deep, and there may be some shallower dents as well. • The indentation / ridge generally extends across the entire area of ​​the buttocks. v.CR-PCSS rating: 4 (severe) • Many very noticeable indentations / ridges Many of the depressions / ridges are thought to be quite deep. • Indentations / ridges are easily noticeable in most buttocks, and smooth skin is rarely or never seen. b. CR-PCSS femur (Figures 3A-3E) i.CR-PCSS rating: 0 (none) • Skin appears smooth Even based on a thorough examination, there are no obvious depressions or ridges. ii. CR-PCSS rating: 1 (almost none) • Very few depressions / undulations • All dents / ridges are very shallow or superficial It is difficult to notice the indentations / undulations unless you look closely. iii. CR-PCSS rating: 2 (mild) • Several noticeable dents / undulations Most depressions / undulations are not considered to be very deep. Most of the thighs have smooth skin, with indentations / ridges scattered or concentrated in certain areas. iv.CR-PCSS rating: 3 (moderate) • Numerous prominent depressions / ridges, most of which are quite distinct. Some of the depressions / ridges are thought to be somewhat deep, but most are thought to be moderately deep, and there may be some shallower ridges as well. • The depressions / undulations generally extend across the entire area of ​​the thigh. v.CR-PCSS rating: 4 (severe) • Many very noticeable dents / undulations Many of the depressions / undulations are thought to be quite deep. • Indentations / undulations are easily apparent on most thighs, and smooth skin is rarely or never seen.

[0066] 3. PR-PCSS The Patient-Reported Photometric Cellulite Severity Scale (PR-PCSS) refers to the photometric scale shown in Figures 2A-2E and 4A-4E, used by patients to quantify their cellulite severity on a five-level scale. More specifically, the PR-PCSS is as follows: a. PR-PCSS gluteal region (Figures 4A-4E) i.PR-PCSS rating: 0 (none) • No obvious cellulite ii. PR-PCSS rating: 1 (almost none) • A few superficial indentations or ridges iii. PR-PCSS rating: 2 (mild) Mostly superficial, with a few indentations or ridges. iv.PR-PCSS rating: 3 (moderate) Mostly, there are numerous, somewhat deep indentations or ridges. v.PR-PCSS rating: 4 (severe) • There are many depressions or ridges covering most of the skin area, many of which are deep. b.PR-PCSS thigh (Figure 2A to Figure 2E) i.PR-PCSS rating: 0 (none) • No obvious cellulite ii. PR-PCSS rating: 1 (almost none) • A few superficial indentations or ridges iii. PR-PCSS rating: 2 (mild) Mostly superficial, with a few indentations or ridges. iv.PR-PCSS rating: 3 (moderate) Mostly, there are numerous, somewhat deep indentations or ridges. v.PR-PCSS rating: 4 (severe) • There are many depressions or ridges covering most of the skin area, many of which are deep.

[0067] Development and verification of E.CR-PCSS and PR-PCSS 1. Introduction The Clinicor-Reported Photo-Quantified Cellulite Severity Scale (CR-PCSS) for the Buttocks and Thighs was developed for clinician use to assess cellulite on the buttocks and posterolateral thighs, while the Patient-Reported Photo-Quantified Cellulite Severity Scale (PR-PCSS) for the Buttocks and Thighs was developed for patient use to rate their own cellulite within the same areas (i.e., left buttock, right buttock, left posterolateral thigh, and right posterolateral thigh). To support clinician assessment and patient self-assessment of cellulite, the CR-PCSS and PR-PCSS scales use the same five reference pictures of the buttocks and posterolateral thighs with varying levels of cellulite severity, specifically varying numbers and depths of indentations. Each reference picture is labeled with an associated severity level (none, almost none, mild, moderate, and severe) along with an accompanying descriptive term. The CR-PCSS scale is shown in Figures 3A-3E and 5A-5E, and the PR-PCSS scale is shown in Figures 2A-2E and 4A-4E.

[0068] The content and content validity of the CR-PCSS device were established through concept elicitation and cognitive interviews. The goal was to develop a user-friendly assessment tool for researchers that would be static, virtually non-comparative in nature, and include response categories corresponding to clinically meaningful grading. In clinical practice, CR-PCSS would be used to assess initial cellulite severity before treatment and then again post-treatment cellulite severity after treatment completion.

[0069] 2. Scale verification CR-PCSS verification using photographs To evaluate the reliability of the device, CR-PCSS was evaluated in a trial-retest study, during which five clinicians rated a total of 200 photographic images representing levels of cellulite severity ranging from none to severe, from 164 subjects available from three different procurement sources. Half of the photographic images were of the gluteal region, and the other half were of the thigh region. Intra-rater and inter-rater reliability of the scale was assessed through assessments conducted at two time points approximately two weeks apart. Intra-rater reliability assessed individual clinician or patient ratings. Inter-rater reliability assessed ratings assigned to groups of clinicians or patients.

[0070] The CR-PCSS demonstrated good reliability, with intra-rater reliability in the gluteal scale ranging from 0.80 to 0.89 for ICC(C,1) and ICC(A,1) (McGraw & Wong 1996), and in the thigh scale ranging from 0.75 to 0.86 for ICC(C,1) and ICC(A,1) (McGraw & Wong 1996). Almost all lower limits of the 95% confidence interval (CI) were above 0.75. ICC(C,1) refers to consistency across assessments, and ICC(A,1) refers to absolute agreement between assessments.

[0071] Intra-rater reliability was calculated for each rater using ICC(C,1) and ICC(A,1). The point estimates for all ICC(C,1) and ICC(A,1) were greater than 0.80. The lower limit of the confidence interval for most ICC(C,1) and ICC(A,1) in the clinician ratings of gluteal images was greater than 0.70. The exception was Clinician 4's ICC(A,1), which had a lower limit of 0.632. The range for ICC(C,1) was 0.840 (0.771, 0.889) to 0.903 (0.860, 0.934), and the range for ICC(A,1) was 0.804 (0.632, 0.887) to 0.894 (0.833, 0.931) [Table 2]. The clinician agreement percentage between assessments ranged from 53% for Clinician 4 to 76% for Clinician 5. [Table 2]

[0072] All ICC(C,1) and ICC(A,1) point estimates were greater than 0.70, and some were greater than 0.80. In 3 out of 5 cases, the lower limit of confidence for ICC(C,1) for clinicians rating the femoral images was greater than 0.70. ICC(C,1) ranged from 0.766 (0.672, 0.836) to 0.859 (0.797, 0.903), and ICC(A,1) ranged from 0.750 (0.412, 0.875) to 0.860 (0.799, 0.904) [Table 3]. The clinician agreement percentage between assessments ranged from 53% for Clinician 4 to 75% for Clinician 1. [Table 3]

[0073] Inter-rater reliability was calculated between raters in Assessment 1 and Assessment 2 using ICC(C,1: degree of consistency across assessments) and ICC(A,1: degree of absolute agreement between assessments). In Assessment 1 (Table 4), the inter-clinician agreement percentage for gluteal images ranged from 53% (Clinician 2 and Clinician 4) to 72% (Clinician 3 and Clinician 5). In Assessment 2 (Table 5), the inter-clinician agreement percentage ranged from 56% (Clinician 2 and Clinician 4) to 73% (Clinician 3 and Clinician 5). [Table 4] [Table 5]

[0074] The lower limit of the ICC confidence interval in Assessment 1 and Assessment 2 was greater than 0.70. In Assessment 1, ICC(C,1) was 0.856 (0.813,0.892) and ICC(A,1) was 0.839 (0.785,0.883). In Assessment 2, ICC(C,1) was 0.845 (0.799,0.884) and ICC(A,1) was 0.834 (0.782,0.877) [Table 6]. [Table 6]

[0075] In Assessment 1, the inter-clinician agreement percentage for thigh images ranged from 39% (Clinician 2 and Clinician 4) to 65% (Clinician 1 and Clinician 5) [Table 7]. In Assessment 2, the inter-clinic agreement percentage ranged from 39% (Clinician 2 and Clinician 4) to 70% (Clinician 1 and Clinician 5) [Table 8]. [Table 7] [Table 8]

[0076] The lower limit of the ICC confidence interval in Assessment 1 and Assessment 2 was greater than 0.70. In Assessment 1, ICC(C,1) was 0.765 (0.702,0.821) and ICC(A,1) was 0.718 (0.616,0.798). In Assessment 2, ICC(C,1) was 0.766 (0.704,0.822) and ICC(A,1) was 0.731 (0.643,0.803) [Table 9]. [Table 9]

[0077] Key research highlights include the following: i. Four out of five clinicians agreed on the rating of 70% or more of the 100-point image for the severity of gluteal cellulite between two assessments; ii. Four out of five clinicians agreed on the rating of 60% or more of the 100-point images for the severity of femoral cellulite between the two assessments; iii. The inter-rater agreement percentage for clinician assessment of 100 photographs ranged from approximately 53% to 76% for the buttocks and from approximately 53% to 75% for the thighs.

[0078] Photographic verification of PR-PCSS The validity of the PR-PCSS content was assessed through concept-elicitation interviews with 26 subjects with cellulite and through cognitive interviews with 23 subjects with cellulite. To evaluate the reliability of the device, the test-retest reliability of PR-PCSS was pre-evaluated in a sample of 99 subjects with varying levels of cellulite severity.

[0079] Cellulite was assessed separately in the thigh and gluteal regions using the PR-PCSS at two visits approximately 14 days apart. At two time points approximately two weeks apart, participants self-assessed their cellulite severity using high-quality photographs taken with a Canfield Vectra® camera. The PR-PCSS demonstrated acceptable reliability for the gluteal scale, with intra-rater estimates of 0.86–0.87 for ICC(C,1) and ICC(A,1), and for the thigh scale, IC The values ​​for C(C,1) and ICC(A,1) were between 0.83 and 0.86, and the lower limit of the 95% confidence interval (CI) across the entire region was above 0.75.

[0080] Patient intra-rater reliability was calculated using ICC(C,1: degree of consistency across assessments) and ICC(A,1: degree of absolute agreement between assessments) [Table 10]. For the left and right buttocks, ICC(C,1) and ICC(A,1) were the same within each quarter: left buttock = 0.87 (95% CI: 0.813, 0.911) and right buttock = 0.86 (95% CI: 0.794, 0.901). This similarity in results within each quarter was also evident in the thigh assessment, with ICC(C,1) being 0.86 (95% CI: 0.793, 0.901) and ICC(A,1) being 0.86 (95% CI: 0.795, 0.902) for the left thigh. The ICC(C,1) in the right thigh was 0.83 (95% CI: 0.755, 0.881) after rounding, and the ICC(A,1) was 0.83 (95% CI: 0.756, 0.882). [Table 10]

[0081] CR-PCSS Live Assessment, Test-Retest Reliability The applicant further conducted a non-intervention study to evaluate the intra- and inter-rater reliability of the CR-PCSS in live patients being assessed by clinicians, and its concordance with the PR-PCSS. More specifically, this study was conducted to evaluate (1) the comparability of two self-assessment methods, one using a mirror for live assessment and the other using a photograph, and (2) the relationship between clinician assessments and self-assessments.

[0082] The trial-retest reliability of the CR-PCSS was assessed at baseline and on day 2. To minimize clinician reliance on memory, patient order was changed on day 2, and clinicians were not allowed to use visual or auditory cues or touch patients. The same patients included in the clinician assessment of the CR-PCSS self-assessed cellulite severity using the PR-PCSS. Either a photograph or a mirror was used at baseline, and the other method was used at day 14. The order of methods was randomly assigned. Intra-rater and inter-rater (CR-PCSS) reliability was estimated using the intraclass correlation coefficient (ICC) for agreement, and the corresponding 95% confidence interval (CI) was calculated. Concordance between CR-PCSS and PR-PCSS assessments was calculated for the left or right buttock and left or right thigh at baseline.

[0083] The six clinicians included as CR-PCSS raters were mostly male (n=5; 83.3%), had an average of 21.3 years of medical practice (ranging from 4 to 54 years), and specialized in either plastic surgery (n=3; 50%) or dermatology (n=3; 50%). The 76 patients had an average age of 45.1 years (ranging from 18 to 71 years), were mostly Caucasian (n=53; 69.7%), and the majority (n=58; 76.3%) self-identified as having cellulite on both their thighs and buttocks. The overall mean (95% CI) ICC score estimates for the intraclinic reliability of CR-PCSS between baseline and day 2 for both the left and right glutes were 0.81 (0.73, 0.90) and 0.81 (0.72, 0.90), respectively, and for the left and right thighs, they were 0.78 (0.67, 0.90) and 0.79 (0.67, 0.90). This demonstrates the reliability of the ICC across the quarter. At baseline, the overall mean (95% CI) ICC score estimates for inter-rater reliability in the left and right gluteal regions were 0.76 (0.69, 0.83) and 0.76 (0.68, 0.82), respectively, and for the left and right thighs, they were 0.74 (0.67, 0.81) and 0.75 (0.68, 0.82). Intra-rater and inter-rater reliability for CR-PCSS was considered acceptable across all regions, with a lower limit estimate of around 0.70 or higher and an upper limit estimate of approximately 0.90 at 95% CI. At baseline, the method-to-method concordance (ICC [95% CI]) between CR-PCSS and PR-PCSS for the left and right glutes was 0.51 (0.32, 0.66) and 0.56 (0.38, 0.70), respectively, and for the left and right thighs it was 0.61 (0.44, 0.73) and 0.67 (0.53, 0.78).

[0084] Intra-rater reliability was assessed through both descriptive tables comparing scores at two assessment points and through the use of ICC. Descriptive analysis revealed that for gluteal assessments, clinicians agreed with themselves 49%–79% of the time over two visits, and within one level of perfect agreement for 89%–92% of that time. For thigh assessments, the rate of perfect agreement was 41%–82% of the time, and agreement was within one level for 93%–94% of that time. Such high rates of variability in intra-clinic concordance are noteworthy, with the lowest self-agreement rates among all cases being either Clinician 6 (protocol deviation above) or Clinician 3. The mean intra-rater ICC was within an acceptable range and consistent across both gluteal regions (left glute ICC(A,1) 0.81, 95% CI 0.725~0.901; right glute ICC(A,1) 0.81, 95% CI 0.718~0.897). For the thigh region, the mean ICC was within an acceptable range and similar across both thigh regions (left thigh ICC(A,1) 0.78, 95% CI 0.670~0.899; right thigh ICC (A,1) 0.79, 95% CI 0.671~0.901).

[0085] Overall, the intra-rater reliability calculated by ICC was within an acceptable range for all regions, with a lower limit estimate of 0.70 or higher and an upper limit estimate of approximately 0.90 for the 95% confidence interval. The gluteal region was observed to have a higher level of intra-rater reliability based on the ICC values ​​compared to the thigh region. [Table 11]

[0086] The mean intrarater ICC was within an acceptable range and consistent across both gluteal regions (left glute ICC(A,1) 0.81, 95% CI 0.725~0.901; right glute ICC(A,1) 0.81, 95% CI 0.718~0.897). For the thigh region, the mean ICC was within an acceptable range and similar across both thigh regions (left thigh ICC(A,1) 0.78, 95% CI 0.670~0.899; right thigh ICC(A,1) 0.79, 95% CI 0.671~0.901).

[0087] Overall, the intra-rater reliability calculated by the ICC is acceptable across all domains. The values ​​were within the range, with a lower limit estimate of 0.70 or higher for the 95% confidence interval and an upper limit estimate of approximately 0.90. The gluteal region was observed to have a higher level of intra-rater confidence based on ICC values ​​compared to the thigh region.

[0088] Inter-rater reliability was similarly assessed using a descriptive format (Section 3.1.3), in addition to the ICC. Agreement rates across gluteal ratings were such that at least four clinicians agreed on 68%–74% of the ratings across the region (left and right) and the time to visit. For the thigh, at least four clinicians agreed on 71–82% of the ratings across the region and the time to visit. A slightly higher level of inter-rater agreement was observed at baseline compared to day 2.

[0089] Across both gluteal regions, the baseline inter-rater reliability assessed by ICC was 0.76 (left gluteal ICC(A,1) 0.76, 95% CI 0.691~0.827; right gluteal ICC(A,1) 0.76, 95% CI 0.68~0.823), and on day 2 it was approximately 0.70 (left gluteal ICC(A,1) 0.71, 95% CI 0.577~0.805; right gluteal ICC(A,1) 0.70, 95% CI 0.56~0.795), which was observed to be within an acceptable range. In both thigh regions, baseline inter-rater reliability assessed by ICC was 0.74 and 0.75 (left thigh ICC(A,1) 0.74, 95% CI 0.67~0.811; right thigh ICC(A,1) 0.75, 95% CI 0.677~0.817), and approximately 0.70 on day 2 (left thigh ICC(A,1) 0.699, 95% CI 0.562~0.798; right thigh ICC(A,1) 0.704, 95% CI 0.566~0.803), which was observed within an acceptable range. Overall, inter-rater reliability calculated by ICC was within an acceptable range for all regions.

[0090] CR-PCSS and PR-PCSS concordance Inter-rater reliability between clinicians and subjects via photographs (left buttock). Inter-rater reliability between CR-PCSS and PR-PCSS was calculated among all six clinicians, and subject ratings were calculated using ICC(C,1) and ICC(A,1). ICC values ​​were generated for each methodology of subject rating in PR-PCSS using either photographs or mirrors. Clinician ratings were randomly selected, and subject photographic ratings were pooled for each subject from assessment baseline and day 14+3. In the table below, "Random Clinician A" and "Random Clinician B" are clinicians randomly selected to match each subject. Their order differs. [Table 12]

[0091] Two randomly selected clinician ratings from photographic images of cellulite (N=75) Inter-rater reliability was compared between the combined target ratings and the ICC(C,1) values. For randomized clinician A, the ICC(C,1) was 0.486 (0.293,0.641) and the ICC(A,1) was 0.460 (0.256,0.623). For clinician B, the ICC(C,1) was 0.641 (0.487,0.757) and the ICC(A,1) was 0.629 (0.467,0.749) [Table 11]. [Table 13]

[0092] The inter-rater reliability between two randomly selected clinician ratings from mirror images of cellulite in the subjects (N=75) and the subject ratings was compared. For random clinician A, the ICC(C,1) was 0.507 (0.319,0.657) and ICC(A,1) was 0.504 (0.316,0.654). For random clinician B, the ICC(C,1) was 0.504 (0.316,0.654) and ICC(A,1) was 0.637 (0. 48,0.754) were included in the study [Table 12]. [Table 14]

[0093] The inter-rater reliability between two randomly selected clinician ratings from photographic images of cellulite in the subjects (N=75) and the subject ratings was compared. For random clinician A ratings, the ICC(C,1) was 0.468 (0.272, 0.627) and the ICC(A,1) was 0.439 (0.231, 0.608). For random clinician B ratings, the ICC(C,1) was 0.524 (0.339, 0.67) and the ICC(A,1) was 0.498 (0.299, 0.654) [Table 13]. [Table 15]

[0094] The inter-rater reliability between two randomly selected clinician ratings from mirror images of cellulite in the subjects (N=75) and the subject ratings was compared. For random clinician A, the ICC(C,1) was 0.606 (0.441,0.731) and the ICC(A,1) was 0.601 (0.435,0.727). For random clinician B, the ICC(C,1) was 0.679 (0.536,0.784) and the ICC(A,1) was 0.677 (0.533,0.783) [Table 14]. [Table 16]

[0095] The inter-rater reliability between two randomly selected clinician ratings from cellulite photographs (N=75) and the control ratings was compared. For random clinician A, the ICC(C,1) was 0.582 (0.41,0.713) and the ICC(A,1) was 0.518. The ratios were (0.253, 0.694). For randomized clinician B, the ICC(C,1) ratio was 0.664 (0.516, 0.773), and the ICC(A,1) ratio was 0.543 (0.116, 0.757) [Table 15]. [Table 17]

[0096] The inter-rater reliability between two randomly selected clinician ratings from mirror images of cellulite in the subjects (N=75) and the subject ratings was compared. For random clinician A, the ICC(C,1) was 0.599 (0.432,0.726) and ICC(A,1) was 0.599 (0.432,0.726). For random clinician B, the ICC(C,1) was 0.617 (0.456,0.74) and ICC(A,1) was 0.620 (0.458,0.742) [Table 16]. [Table 18]

[0097] The inter-rater reliability between two randomly selected clinician ratings from cellulite photographs (N=75) and the control ratings was compared. For random clinician A ratings, the ICC(C,1) was 0.640 (0.486,0.756) and the ICC(A,1) was 0.575 (0.300,0.742). For random clinician B ratings, the ICC(C,1) was 0.690 (0.551,0.792) and the ICC(A,1) was 0.558 (0.093,0.776) [Table 17]. [Table 19]

[0098] The inter-rater reliability between two randomly selected clinician ratings from mirror images (N-75) of cellulite in the subjects and the subject ratings was compared. For random clinician A, the ICC(C,1) was 0.615 (0.452,0.738) and the ICC(A,1) was 0.617 (0.455,0.74). For random clinician B, the ICC(C,1) was 0.642 (0.488,0.758) and the ICC(A,1) was 0.639 (0.484,0.755) [Table 18]. [Table 20]

[0099] Inter-rater reliability between two randomly selected clinician ratings and control ratings from pooled analyses using both methods (mirror and photograph) was compared at baseline. For randomized clinician A, the ICC(C,1) was 0.515 (0.328,0.663) and the ICC(A,1) was 0.505 (0.317,0.655). For randomized clinician B, the ICC(C,1) was 0.668 (0.521,0.776) and the ICC(A,1) was 0.667 (0.521,0.776) [Table 19]. [Table 21]

[0100] Inter-rater reliability between two randomly selected clinician ratings and control ratings from pooled analyses using both methods (mirror and photograph) was compared at baseline. For randomized clinician A, the ICC(C,1) was 0.563 (0.387,0.699) and the ICC(A,1) was 0.557 (0.381,0.695). For randomized clinician B, the ICC(C,1) was 0.592 (0.423,0.721) and the ICC(A,1) was 0.59 (0.421,0.719) [Table 20]. [Table 22]

[0101] The inter-rater reliability between two randomly selected clinician ratings and control ratings from pooled analyses using both methods (mirror and photograph) was compared at baseline. For random clinician A, the ICC(C,1) was 0.609 (0.445,0.733). Yes, and the ICC(A,1) was 0.607 (0.443,0.732). For randomized clinician B, the ICC(C,1) was 0.615 (0.452,0.738), The ICC(A,1) was 0.592 (0.413,0.725) [Table 21].

[0102] Across both gluteal regions, the baseline inter-rater reliability assessed by ICC was 0.76 (left gluteal ICC(A,1) 0.76, 95% CI 0.691~0.827; right gluteal ICC(A,1) 0.76, 95% CI 0.68~0.823), and on day 2 it was approximately 0.70 (left gluteal ICC(A,1) 0.71, 95% CI 0.577~0.805; right gluteal ICC(A,1) 0.70, 95% CI 0.56~0.795), which was observed to be within an acceptable range.

[0103] For both thigh regions, the baseline inter-rater reliability assessed by ICC was 0.74 and 0.75 (left thigh ICC(A,1) 0.74, 95% CI 0.67~0.811; right thigh ICC(A,1) 0.75, 95% CI 0.677~0.817), and approximately 0.70 on day 2 (left thigh ICC(A,1) 0.699, 95% CI 0.562~0.798; right thigh ICC(A,1) 0.704, 95% CI 0.566~0.803), which was observed to be within an acceptable range. Overall, the inter-rater reliability calculated by ICC was within an acceptable range for all regions.

[0104] The above describes two integrated studies evaluating CR-PCSS and PR-PCSS. Because all previous validation work based on these scales had been conducted using photographs, the CR-PCSS study was designed to provide a robust assessment of the test-retest reliability of CR-PCSS when using live assessment of cellulite severity in subjects present in situ. The PR-PCSS study was conducted to assess the concordance of methods between self-assessments conducted using mirrors and photographs. Another objective of the study was to assess the comparability of CR-PCSS and PR-PCSS.

[0105] These analyses supported the conclusion that the scale demonstrated good reliability over time across all domains as an assessment of cellulite severity. Almost all score estimates for intra-rater reliability were clearly within acceptable limits. The mean ICC(A,1) was 0.81 (SD=0.08), with a range of 0.69–0.91 and a lower limit of the confidence interval of 0.53–0.86. All comparable results for ICC(C,1) were slightly higher.

[0106] The results of PR-PCSS were evaluated for their correspondence with CR-PCSS and for the comparability of self-assessment using mirrors versus photographs. The results of the ICC analysis showed that clinicians tended to be more consistent with subjects who self-assessed using mirrors rather than photographs, with ICC(A,1) ranging from 0.50 to 0.68 for mirrors and from 0.44 to 0.63 for photographs.

[0107] Comparison of PR-PCSS methods Comparability of the PR-PCSS method was calculated for each domain among subjects by alternating the days of photographic and mirror assessment. This was calculated using ICC(C,1: degree of consistency across assessments) and ICC(A,1: degree of absolute agreement within assessments). Intrarater reliability for each domain was assessed in subjects who self-assessed using mirrors at baseline and photographs on day 14+3. Seven out of eight point estimates were >0.7, with the exception of ICC(A,1) of 0.696 for the left thigh. The lower limit confidence interval was wide, ranging from 0.304 to 0.669. ICC(C,1) ranged from 0.745 (0.556, 0.861) for the right buttock to 0.815 (0.669, 0.901) for the left buttock. The ICC(A,1) ranged from 0.696 (0.304,0.860) in the left thigh to 0.811 (0.662,0.899) in the left buttock.

[0108] In subjects who used a mirror at baseline and self-assessed using photographs on day 14+3, The intra-rater reliability for each domain was evaluated. All eight point estimates were <0.7. The lower limit confidence interval was wide, ranging from 0.068 to 0.495. The ICC(C,1) ranged from 0.601 (0.358,0.768) for the right thigh to 0.697 (0.495,0.829) for the left hip. The ICC(A,1) ranged from 0.484 (0.068,0.730) for the right thigh to 0.683 (0.471,0.821) for the left hip.

[0109] Inter-rater reliability between CR-PCSS and PR-PCSS was calculated among all six clinicians, and subject ratings were calculated using ICC(C,1) and ICC(A,1). ICC values ​​were generated for each methodology of subject rating in PR-PCSS using either photographs or mirrors. Clinician ratings were randomly selected, and subject photograph ratings were pooled for each subject from assessment baseline and day 14+3. In the table below, "Random Clinician A" and "Random Clinician B" are clinicians randomly selected to match each subject. Their order differs.

[0110] The comparability of the PR-PCSS method was calculated by alternating the dates of photographic and mirror assessments for each domain across the subjects. This was calculated using ICC(C,1: degree of consistency across assessments) and ICC(A,1: degree of absolute agreement between assessments).

[0111] Intra-rater reliability for each domain was assessed in subjects who self-assessed using a mirror at baseline and using photographs on day 14+3. Seven out of eight point estimates were >0.7, with the exception of 0.696 for ICC(A,1) for the left thigh. The lower limit confidence interval was wide, ranging from 0.304 to 0.669. ICC(C,1) ranged from 0.745 (0.556,0.861) for the right gluteus to 0.815 (0.669,0.901) for the left gluteus. ICC(A,1) ranged from 0.696 (0.304,0.860) for the left thigh to 0.811 (0.662,0.899) for the left gluteus.

[0112] Intra-rater reliability for each domain was assessed in subjects who self-assessed using a mirror at baseline and using photographs on day 14+3. All eight point estimates were <0.7. The lower limit confidence intervals were wide, ranging from 0.068 to 0.495. ICC(C,1) ranged from 0.601 (0.358,0.768) in the right thigh to 0.697 (0.495,0.829) in the left gluteal region. ICC(A,1) ranged from 0.484 (0.068,0.730) in the right thigh to 0.683 (0.471,0.821) in the left gluteal region.

[0113] In summary, the applicant demonstrated the test-retest reliability and interrater reliability of the CR-PCSS in subjects present at the time. The CR-PCSS and PR-PCSS yielded acceptablely comparable ratings when comparing clinician ratings with subject self-ratings. The CR-PCSS was determined to be a reliable tool for assessing the severity of cellulite in the buttocks and thighs. Furthermore, the CR-PCSS correlated well with the PR-PCSS. Therefore, the CR-PCSS and PR-PCSS are valid and reliable tools for assessing cellulite severity.

[0114] F. Use of scales in assessment and treatment 1. Overview In one embodiment, the present disclosure is a method for assessing the severity of cellulite on the thigh or buttocks in a human subject, a. Assess the quarter of the thigh or buttock surface of the subject showing signs of cellulite, b. Assessing the severity of the cellulite in question, including using a validated photometric scale or the CR-PCSS or PR-PCSS scale, c. Using the images, determine the severity of the cellulite in the subject, using at least five steps of increase in severity. Classifying into classes and This provides a method that includes [something].

[0115] A method for assessing the severity of cellulite on the thighs in human subjects, as described herein and shown in Figures 3A to 3E, a. Assess the quarter of the thigh surface of the subject showing signs of cellulite, b. Assessing the severity of cellulite in the subject, including using the CR-PCSS scale, c. Using images, classify the severity of the cellulite in question into at least five classes of increasing severity, where the lowest class (0) means no depressions or raised areas, class 1 means a few depressions or ridges that are mostly superficial, class 2 means several shallow ridges with slight raised areas, class 3 means numerous ridges that are mostly moderate in depth with alternating raised and depressed areas, and class 4 means many ridges that are some more severe in depth with alternating raised and depressed areas. There are methods that include this.

[0116] A method for assessing the severity of cellulite on the thighs in human subjects, as described herein and shown in Figures 2A to 2E, a. Assess the quarter of the thigh surface of the subject showing signs of cellulite, b. Assessing the severity of the cellulite in the subject, including using the PR-PCSS scale, c. Using images, classify the severity of the cellulite in the subject into at least five classes of increasing severity, where the lowest class (0) means no obvious cellulite, class 1 means a few superficial depressions or ridges, class 2 means several mostly superficial depressions or ridges, class 3 means many mostly somewhat deep depressions or ridges, and class 4 means many deep depressions or ridges covering most of the skin area. There are methods that include this.

[0117] A method for assessing the severity of cellulite on the buttocks in human subjects, as described herein and shown in Figures 4A to 4E, a. To assess the surface of the buttocks of the subject showing signs of cellulite, b. Assessing the severity of cellulite in the subject, including using the PR-PCSS scale, c. Using images, classify the severity of the cellulite in the subject into at least five classes of increasing severity, where the lowest class (0) means no obvious cellulite, class 1 means a few superficial depressions or ridges, class 2 means several mostly superficial depressions or ridges, class 3 means many mostly somewhat deep depressions or ridges, and class 4 means many deep depressions or ridges covering most of the skin area. There are methods that include this.

[0118] A method for assessing the severity of cellulite on the buttocks in human subjects, as described herein and shown in Figures 5A to 5E, a. To assess the surface of the buttocks of a subject showing signs of cellulite, b. Assessing the severity of cellulite in the subject, including using the CR-PCSS scale, c. Using images, classify the cellulite severity of the subject into at least five classes of increasing severity, where the lowest class (0) means no indentations or obvious cellulite, class 1 means a few indentations that are mostly superficial, class 2 means several indentations that are mostly shallow, class 3 means many indentations that are mostly moderate, and class 4 means many indentations that have some more severe depths. There are methods that include this.

[0119] This method may optionally include the use of PR-PCSS alone or in combination with CR-PCSS.

[0120] Furthermore, a method for assessing the severity of cellulite in human subjects, a. Select a portion of the thigh or buttocks to be evaluated, b. Comparing the relevant portion of the thigh or buttocks with a series of photographs, each having a corresponding number as shown in Figures 2 to 5, c. Identify a photograph that most closely resembles the appearance of the selected portion of the thigh or buttocks, d. Including reading the numbers corresponding to the identified photographs, There are methods that use scales to ensure consistency among at least 50% of evaluators.

[0121] In other embodiments, when the CR-PCSS scale is used by multiple clinicians, at least 40% of the clinicians give the patient the same rating when the patient is screened and from day 1 of treatment. Alternatively, such clinicians give such the same rating to at least about 50%, or about 60%, or about 70%, or about 80%, or about 90%, or about 100% of the patients.

[0122] 2. Use of CR-PCSS by clinicians In practice, the CR-PCSS gluteal scale (Figures 5A–5E) is used when a clinician is evaluating the left or right gluteal region. The CR-PCSS thigh scale (Figures 3A–3E) is used when evaluating the left or right posterolateral thigh. The clinician then determines which cellulite picture with labels and descriptive terms on the CR-PCSS best resembles the cellulite in the quarter being evaluated. The scale-to-patient matching may be done in situ or by the clinician analyzing the images. The cellulite severity score that most closely matches the cellulite in the quarter is assigned to the quarter for a particular visit. In one embodiment, if the clinician feels that the patient's quarter is exactly in the middle of two severity levels, the clinician will choose the higher severity level.

[0123] In another embodiment, the quarter-sectional digital image is captured with a high-quality digital camera (e.g., Canfield Scientific's VECTRA 3-D camera). The digital image is then displayed on a high-resolution monitor. The quarter-sectional images appear one by one, and the clinician evaluates the image, assesses its cellulite severity, and then moves on to evaluating the next image. Instead of digital images, other images (e.g., photographs) are evaluated and assessed.

[0124] 3. Patient use of PR-PCSS In practice, the PR-PCSS gluteal scale (Figures 4A-4E) is used when the patient is evaluating their left or right gluteal region. The PR-PCSS thigh scale (Figures 2A-2E) is used when either the left posterolateral thigh or the right posterolateral thigh is being evaluated. Next, the patient determines which PR-PCSS cellulite picture, with its labels and descriptive terms, most closely resembles the cellulite within the evaluated quarter. (Score and quarter) Matching to a specific area may be done in situ (through a mirror) or by analyzing an image. The cellulite severity score closest to the cellulite in a quarter is assigned to that quarter for a particular visit. In one embodiment, if a patient feels that their quarter is exactly in the middle of two severity levels, the patient will choose the higher severity level.

[0125] G. Treatment method, therapeutic endpoint, and efficacy This disclosure provides a method for treating cellulite in a human patient requiring treatment for cellulite, comprising (a) a pharmaceutical formulation comprising a mixture of collagenase I and collagenase II obtained from or derived from Clostridium histolyticum having a specific activity of about 5,000 ABC units / mg to 25,000 ABC units / mg, and (b) injecting the pharmaceutical formulation into the collagenous septal network of cellulite at a dose of about 0.1 mg to 5 mg, wherein the patient has an improvement of 2 points or more from baseline for CR-PCSS at 71 days post-treatment. Furthermore, an improvement of 2 points or more from baseline at 71 days may be shown for both CR-PCSS and PR-PCSS. In another embodiment, such treatment may result in an improvement of 1 point or more or 3 points or more from baseline for one or both CR-PCSS and PR-PCSS at 71 days post-treatment. In addition, improvements of 3 points or more, 2 points or more, or 1 point or more may be seen approximately 6 months or 12 months after treatment with either CR-PCSS or PR-PCSS or both. Furthermore, such patients may have improvements of 3 points or more, 2 points or more, or 1 point or more from baseline for both CR-PCSS and PR-PCSS approximately 22, 43, 90, or 180 days after treatment. This improvement may be seen approximately 15, 25, 35, 45, 55, 65, 75, 85, or 95 days after treatment.

[0126] The above treatment method may include approximately 1 to 10 treatment sessions, approximately 2 to 5 treatment sessions, or approximately 3 treatment sessions. Each treatment session may include administering a mixture of collagenase I and II as the sole active ingredients in the pharmaceutical formulation. Collagenase I and II may be present in a ratio of approximately 1:1 or in any other ratio as described above. Each of collagenase I and II may have an area purity of at least 80% as measured by RP-HPLC, or at least 85%, at least 90%, at least 95%, or at least 100% as measured by RP-HPLC. Alternatively, other scales described herein may be used instead of CR-PCSS and PR-PCSS to assess the effectiveness of the treatment and improvement in cellulite appearance at 71 days, 6 months, or 12 months after one or more treatment sessions.

[0127] Such treatment may be performed on a statistically significant population of human patients, particularly women, who demonstrate a statistically significant improvement measured by 2 points or more in both the CR-PCSS and PR-PCSS scores. The percentage of patients experiencing such improvement may be at least 10%, or at least 20%, or at least 25%, or at least 30%, or at least 35%, or at least 40%, or at least 45%, or at least 50%, or at least 55%, or at least 60%, or at least 65%, or at least 70%, or at least 75%, or at least 80%, or at least 85%, or at least 90%. Similar percentages of improvement may also be seen in patients who demonstrate an improvement of 1 point or more, or 3 points or more, in both the CR-PCSS and PR-PCSS scores at 71 days, or 6 months, or 12 months after treatment. Furthermore, the procedure is performed using one or more of the following: GAIS, CSI, SR-CIS, SCTA, SGA-C, GAIS-C, S-GAIS, and I-GAIS, and measurements are taken 71 days, 6 months, or 12 months after the procedure. The patient population also showed statistically significant improvement.

[0128] In another embodiment, the patient receives up to three treatment visits of CCH injections (0.84 mg / treatment area, two treatment areas per visit), with each treatment visit occurring approximately every 21 days. Between visits, 12 injections are administered into the cellulite depressions across each affected area (left and right buttocks). At both the beginning and end of the treatment, cellulite severity is assessed by each patient and clinician using two validated photoquantified cellulite severity scales, e.g., CR-PCSS and PR-PCSS. The primary endpoint is a composite responder analysis demonstrating at least two levels of composite improvement, independently reported by both the patient and clinician on the photoquantified cellulite severity scale. Key secondary endpoints may include the percentage of subjects experiencing at least one or two levels of improvement in patient-reported assessment, the percentage of subjects with one level of composite improvement, the percentage of subjects who were satisfied, the Cellulite Impact Scale, i.e., the change from baseline in the patient's self-perception of their own cellulite, and the percentage of subjects with at least one or two levels of improvement on the Global Aesthetic Improvement Scale (GAIS). In another embodiment, the patient receives treatment on one to four affected areas per visit.

[0129] In a further embodiment, when CR-PCSS is used by multiple clinicians, at least 40% of the clinicians give the same cellulite severity rating to the patient's cellulite areas when the patient is screened and from day 1 pre-treatment. In other embodiments, at least 50%, 60%, 70%, 80%, 90%, or 100% of the clinicians give the same cellulite severity rating to the patient's cellulite areas when the patient is screened and from immediately before the first treatment session (i.e., day 1 pre-treatment). Such consistency of ratings is also observed at a time point selected from a group consisting of screening, day 1 pre-treatment, day 30 post-treatment, day 60 post-treatment, day 120 post-treatment, day 180 post-treatment, and 12 months post-treatment. Multiple clinicians may include 2 to 10 clinicians. Furthermore, CR-PCSS and PR-PCSS may be used to assess the severity of cellulite by one or more of the following methods: live assessment by viewing digital images of the cellulite area, live assessment by viewing photographs of the cellulite area, and live assessment by viewing mirror images of the cellulite area.

[0130] In one embodiment, collagenase is injected into the affected area as shown in Figure 7. The injection interval can vary from approximately 0.1 cm to 15 cm, or from approximately 1 cm to 10 cm, or from approximately 0.5 cm to 2 cm.

[0131] Furthermore, in certain embodiments, the inter-rater reliability between clinicians and subjects between CR-PCSS and PR-PCSS may include the following: • Left buttock (mirror or photograph): ICC(C,1) is approximately 0.2 to 0.8, ICC(A,1) is approximately 0.2 to 0.8 • Right buttock (mirror or photograph): ICC(C,1) is approximately 0.2 to 0.8, ICC(A,1) is approximately 0.2 to 0.8 • Left thigh (mirror or photograph): ICC(C,1) is approximately 0.3 to 0.9, ICC(A,1) is approximately 0.1 to 0.8 Right thigh (mirror or photograph): ICC(C,1) is approximately 0.3 to 0.9, ICC(A,1) is approximately 0.2 to 0.3

[0132] In other embodiments, using CR-PCSS, clinicians agreed with themselves approximately 40% to 90% of the time spent on rating the glutes. For rating the thighs, clinicians agreed with themselves approximately 40% to 90% of the time spent. Inter-rater ICC for the left and right glutes was approximately 0. The range is 0.6 to 0.95 (ICC(A,1)), and the 95% CI is approximately 0.6 to 0.95. For the femoral region, the ICC range is approximately 0.6 to 0.95 (ICC(A,1)), and the 95% CI is approximately 0.6 to 0.95.

[0133] The CR-PCSS inter-rater reliability shows approximately 60%–95% clinician agreement for both the thigh and gluteal regions. The ICC can range from approximately 0.5 to approximately 0.9 (ICC(A,1)).

[0134] In another embodiment, the treatment method evaluated the persistence of the effect in two-level composite responders (patients who had at least two levels of improvement in cellulite severity in both PR-PCSS and CR-PCSS), yielding statistically significant figures demonstrating persistence of the effect at 6 and 12 months. In certain embodiments, at least about 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100% of patients demonstrated such persistence. [Examples]

[0135] H. Examples The following examples are included to demonstrate certain embodiments of the present disclosure. However, those skilled in the art will understand that modifications may be made in light of the present disclosure to the particular embodiments disclosed, and that similar or identical results may still be obtained without departing from the spirit and scope of the invention. Accordingly, all matters described herein should be construed as illustrative and not restrictive.

[0136] Example 1: Efficacy and safety of CCH for the treatment of EFP In a Phase 2a clinical trial of CCH for the treatment of cellulite, the applicant demonstrated that three doses of CCH (XIAFLEX®) (low dose (0.06 mg), medium dose (0.48 mg), and high dose (0.84 mg)) showed improvement in the appearance of cellulite, as measured by the investigator's trial endpoint and patient scores on the Global Aesthetic Improvement Scale (GAIS) adapted for use in cellulite. The medium-dose and high-dose groups demonstrated statistically significant improvement in the appearance of cellulite, as measured by the GAIS score, with p-values ​​< 0.05 compared to placebo for both endpoints. In the medium-dose and high-dose groups, 68 percent of patients reported being “satisfied” or “very satisfied” with the treatment results, compared to only 34 percent in patients randomized to placebo. CCH showed good tolerance in all dose groups, and most adverse events (AEs) were mild to moderate and mainly limited to the local injection area.

[0137] Next, the applicant conducted a Phase 2b clinical trial, enrolling 375 women aged 18 years or older in the United States with moderate to severe cellulite. Each subject received up to three treatment sessions of CCH (0.84 mg / session) or placebo, with each treatment session occurring approximately 21 days apart. Twelve injections were administered into the cellulite depressions between each session across the entire treatment quarter (left or right buttock, or left or right posterolateral thigh). Cellulite severity was assessed by each patient and clinician at both the beginning and end of the study period (28 days after the last treatment) using two photoquantified cellulite severity scales, namely PR-PCSS and CR-PCSS described above. Patient demographic characteristics and other information included: ■ Moderate or severe EFP in the left or right buttock or posterolateral thigh • CR-PCSS score and PR-PCSS score in one or more quarters are 3-4, and the total Hexsel CSS score is 13 or less. ■ No history of keloid scarring or abnormal wound healing. ■ There are no active skin alterations (e.g., rash, eczema, skin cancer) within the area to be treated. ■ No liposuction has been performed on the selected side of the body in the past 12 months. ■None of the following have been performed on the selected quarter of the body. • Injections (e.g., mesotherapy), laser treatments, or surgeries within the past 12 months • Endermologie treatments over the past 6 months • Massage treatments within the past 3 months • EFP cream used over the past two months

[0138] More specifically, the patient population and demographic characteristics were as follows: 375 registered patients (mean age 46.5 years; 86.4% were Caucasian). [Table 23]

[0139] The Phase 2b trial was randomized, double-blind, placebo-controlled. The primary endpoint was the proportion of composite responders at day 71 who had a 2-point improvement in severity from baseline on the clinician-reported (CR-PCSS) scale and a 2-point improvement on the patient-reported (PR-PCSS) scale. Additional endpoints included composite responders with a 1-point improvement, the percentage of responders with 1-point and 2-point improvements on the CR-PCSS and PR-PCSS, patient and clinician assessment of improvement using the Global Aesthetic Improvement Scale (GAIS), participant satisfaction, and change on the Hexsel Cellulite Severity Scale. The study included adult women with moderate to severe edematous fibrosclerosing subcutaneous adipose tissue abnormalities on at least one quarter of the right or left buttock or posterolateral thigh. Quarters were randomly assigned if a patient had two or more eligible quarters. Patients were randomly divided into 1:1 groups and injected either placebo or collagenase Clostridium histolyticum (EN3835) or XIAFLEX® 0.84 mg into a depression within a selected quarter. Patients could receive up to three treatment sessions. Each treatment session consisted of 12 injections of XIAFLEX® (0.3 mL) into the selected quarter. Each session was spaced approximately 21 days apart. Figure 8 is a schematic diagram of the study design.

[0140] The primary endpoint is 71 days for composite responders (defined as individuals showing an improvement of 2 points or more from baseline on both the clinician-reported and patient-reported photoquantified cellulite severity scale scores). This was expressed as a percentage in the eyes.

[0141] The secondary endpoint was the percentage of composite responders (defined as individuals showing an improvement of 1 point or more from baseline in both the clinician-reported and patient-reported photoquantified cellulite severity scale scores) at day 71.

[0142] Researchers and subjects were assessed on day 71 using the Global Aesthetic Improvement Scale and the Hexsel Cellulite Severity Scale.

[0143] Of the 489 patients screened, 189 were randomly assigned to receive the collagenase Clostridium histolyticum (CCH) 0.84 mg, and 186 to receive a placebo, each receiving at least one injection (safety and intention to treat (ITT) population).

[0144] The primary endpoint (i.e., the percentage of patients who showed an improvement of 2 points or more from baseline in the clinician-reported photoquantified cellulite severity scale [CR-PCSS] and the patient-reported photoquantified cellulite severity scale score [PR-PCSS]) was evaluated in the ITT population.

[0145] All secondary efficacy analyses were performed in the modified intention-to-treatment population (i.e., patients who were randomly assigned, received at least one injection, and had CR-PCSS and PR-CSS scores after at least one injection).

[0146] In the ITT population, mean patient age, race, and body mass index categories were similar within the CCH population and the placebo population. The following results were obtained in the intention-to-treat population: ●On day 71, patients who received a statistically higher percentage of collagenase Clostridium histolyticum (CCH) compared to placebo showed an improvement of 2 points or more on the photoquantified cellulite severity scale, as reported by both clinicians and patients (primary endpoint; P<0.001). ●On day 71, patients who received a statistically higher percentage of CCH compared to placebo showed an improvement of 1 point or more on the photoquantified cellulite severity scale, as reported by both clinicians and patients (secondary endpoint; P<0.001). ●On day 71, statistically significant higher improvement was observed compared to placebo with collagenase Clostridium histolyticum on various researcher and patient scales (P<0.001 for all). A higher percentage of patients who received the collagenase Clostridium histolyticum (CCH) (82.0%) reported adverse events (AEs) related to the treatment compared to patients who received placebo (26.9%). However, most AEs in the CCH group were mild in severity (65.7% [468 / 712]; severity data not shown). ●Only about 4% of AEs were the reason patients discontinued CCH treatment. ●Procedure-related adverse events occurred in 81.5% of patients in the CCH group and 18.3% of patients in the placebo group. ●The most common procedure-related adverse events in both groups were bruising at the injection site (CCH, 75.1%; placebo, 12.9%) and pain at the injection site (CCH, 59.3%; placebo, 5.4%). ● Treatment with CCH significantly improved clinician and patient ratings of EFP appearance compared to placebo. The key Phase 2b trial results also included the following: ● Subjects who received CCH demonstrated a highly statistically significant improvement in the composite researcher and patient assessment primary endpoint of cellulite appearance, as measured by a 2-point improvement in both the CR-PCSS score and the PR-PCSS score (p-value < 0.001 compared to placebo). ● Subjects who received CCH demonstrated highly statistically significant improvement in composite researcher and patient assessments of cellulite appearance, as measured by a 1-point improvement in both the CR-PCSS score and the PR-PCSS score (p-value < 0.001 compared to placebo). ● A significantly higher proportion of CCH subjects reported being "satisfied" or "very satisfied" with cellulite treatment compared to the placebo group (p-value < 0.001). ● A very significant proportion of CCH subjects reported "improvement," "significant improvement," or "very significant improvement" in the overall appearance of the cellulite area compared to the placebo group (p<0.001). ●CCH showed good tolerance to all dose groups, and most adverse events (AEs) were mild to moderate and mainly limited to the local injection area; of all associated AEs, 92 percent in the CCH group were mild to moderate, compared to 96 percent in the placebo group; the most common AEs were expected and included injection site bruising (approximately 75 percent) and injection site pain (approximately 59 percent). ●Figures 6A and 6B are a series of photographs showing cellulite in the buttocks of two patients treated with CCH or placebo, respectively, with either a 2-point improvement in the CR-PCSS and PR-PCSS ratings, or no change in the ratings. ●Figure 9 is a graph reporting the composite response of the primary and secondary endpoints at 71 days after CCH treatment or placebo. ●Figures 10A and 10B are a series of photographs showing pre- and post-treatment cellulite in the buttocks of a patient treated with CCH, exhibiting a composite response of 2 points from baseline assessment. ●Figures 11A and 11B are a series of photographs showing pre- and post-treatment cellulite in the buttocks of a patient treated with CCH, exhibiting a composite response of 1 point from baseline assessment. ●Figures 12A and 12B are a series of photographs showing before and after cellulite in the buttocks of a patient treated with CCH and showing a 1-point response based on PR-PCSS. ●Figures 13A and 13B are a series of photographs showing cellulite on the buttocks of patients who were treated with placebo and showed no change in CR-PCSS score or PR-PCSS score. ●Overall, CCH treatment generally showed good resistance. The rate of patient discontinuation due to adverse events (AEs) was low (3.7%). Further clinical evaluation of CCH for EFP (cellulite) is needed.

[0147] Further details regarding other efficacy measures and safety profiles are shown in the following table. [Table 24] [Table 25]

[0148] The results of the Phase 2b study demonstrate that the treatment (three visits approximately 21 days apart) improves cellulite severity in the treated area, as assessed by the primary endpoint of a two-level composite responder analysis. The proportion of responders based on two or more levels of improvement in cellulite appearance in both patient PR-PCSS and clinician CR-PCSS for the buttocks and thighs was statistically significantly higher in the subjects receiving EN3835 0.84 mg (10.6%; P<0.001) compared to the placebo subjects (1.6%). The number of responders with one level (or more) in PR-PCSS in the EN3835-treated subjects (72.3%) was significantly higher than the number of responders with one level in the placebo group (51.6%) (p<0.001). The statistically significant (p≦0.001) improvement in cellulite appearance based on the subject S-GAIS was higher in the EN3835 group compared to the placebo group (44.0%). Observed in the 0.84 mg group (73.1%), 62.9% of subjects in the EN3835 0.84 mg group were satisfied or very satisfied with the results of their cellulite treatment, compared to only 35.9% in the placebo group (p<0.001). In subjects treated on the buttocks (n=187), the proportion of composite respondents with two levels was statistically significantly higher in the EN3835 0.84 mg group compared to the placebo group, and the proportion of subjects with one level (or more) of PR-PCSS in the EN3835-treated group was higher in the placebo group. This was significantly more common than the number of respondents at level 1.

[0149] Statistical analysis of additional evidence regarding the reliability and validity of CR-PCSS and PR-PCSS supported their effectiveness. More specifically, the agreement between the right and left buttocks indicated that both scales could be used to yield very high levels of agreement, and clinician results showed higher agreement (i.e., approximately 5%, 10%, 15%, 20%, and 30% higher than in patients using PR-PCSS). Clinicians demonstrated good inter-rater reliability in their ratings. These results support the use of CR-PCSS and CR-PCSS devices as endpoints for treating cellulite.

[0150] Furthermore, Figures 14 and 15 show that the likelihood of achieving a -3, -2, or -1 change in CR-PCSS (a reduction of 3, 2, or 1 level, respectively) on day 71 is higher in EN3835-treated patients than in placebo-treated patients. Aggressive treatment results in a higher percentage of patients demonstrating the clinical effectiveness of EN3835 across all levels of change scores. Similarly, Figures 16 and 17 show that the likelihood of achieving a -3, -2, or -1 change in PR-PCSS (a reduction of 3, 2, or 1 level, respectively) on day 71 is higher in EN3835-treated patients than in placebo-treated patients. Aggressive treatment results in a higher percentage of patients demonstrating the clinical effectiveness of EN3835 across all levels of change scores.

[0151] Furthermore, this study demonstrated that EN3835 exhibits good tolerance without serious adverse events (SAEs) associated with EN3835. Safety results from a total of four studies (one pilot study, two phase 1 studies, and two phase 2 studies) in which 435 adult women received subcutaneous injections of EN3835 showed that the majority of treatment-related adverse events (TEAEs) were transient, non-serious, mild to moderate in severity, and related to the topical administration of EN3835. Immunogenicity profiles after three EN3835 treatments showed that more than 90% of those treated with EN3835 had positive blood reactions for collagenase I and / or collagenase II antibodies, but this EN3835 profile is similar to those observed in programs for Dupuytren's contracture and Peyronie's disease.

[0152] Example 2: Comparison of cellulite severity scales based on clinician reports and patient reports with existing cellulite severity measurement scales. The Hexsel Cellulite Severity Scale (CSS) is the current assessment tool for measuring the severity of cellulite. The Hexsel CSS rates each of the five domains of cellulite (number of obvious depressions, depth of depressions, morphological alteration of the skin surface, skin laxity, skin looseness or sagging, and the Nurnberger and Muller classification) on a scale from "0" (no alteration) to "3" (most severe).

[0153] In a Phase 2 trial, adult women with edematous fibrosclerosing subcutaneous adipose tissue abnormalities (cellulite) assessed four anatomical quarters of the buttocks and posterolateral thigh at screening using PR-PCSS. Clinicians assessed the same four quarters and reported cellulite severity using CR-PCSS and Hexsel CSS. Patients with one or more quarters showing moderate or severe cellulite (i.e., a CR-PCSS score of 3 or 4, a PR-PCSS score of 3 or 4, and a Hexsel CSS score of 13 or less) at screening and on day 1 were randomly assigned to receive either pharmacological treatment or placebo within one cellulite quarter. CR-PCSS, PR-PCSS, and Hexsel CSS were used at screening and on days 1, 22, 43, and 71. The study was completed on day 71. The Targeted Global Aesthetic Improvement Scale (S-GAIS), which assesses cellulite improvement using a patient rating scale from 3 ("significantly improved") to -3 ("significantly worsened"), was completed. Spearman's rank correlation coefficient was used to assess the agreement between CR-PCSS and Hexsel CSS, between CR-PCSS and PR-PCSS, and between the mean change in PR-PCSS from day 1 to day 71 and the S-GAIS score at day 71.

[0154] A total of 375 patients were randomized for treatment and received one or more treatment sessions (intent to treat [ITT]). Ratings on CR-PCSS, PR-PCSS, and Hexsel CSS at screening (N=1500) were included in the correlation calculations. CR-PCSS scores were significantly correlated with the Hexsel CSS total score overall (P<0.001), and also in the thigh (P<0.001) and gluteal regions (P<0.001). Significant correlations were also observed between clinician and patient rating scales (CR-PCSS and PR-PCSS) overall (P<0.001) and within each target region (P<0.001 for both). In patients within the modified ITT population (patients within ITT with one or more CR-PCSS and PR-CSS assessments after injection, n=352), the mean change in PR-PCSS score correlated with the rating of aesthetic change on the S-GAIS (P<0.001).

[0155] Based on the applicant's findings, CR-PCSS is a simpler method for physicians to assess cellulite (i.e., a single item compared to the 5-domain Hexsel scale). The positive correlations between CR-PCSS and the Hexsel CSS total score, and between PR-PCSS and S-GAIS, support the validity of CR-PCSS and PR-PCSS in terms of standard scales (Hexsel CSS and S-GAIS). The correlation of PR-PCSS with CR-PCSS (P<0.001) indicates that the two scales assess disease status similarly (i.e., a static assessment of cellulite severity).

[0156] Example 3 Assessment of cellulite severity: Test-retest reliability and concordance between novel clinician-reported and patient-reported photodigital scales Background: The clinician-reported photometric cellulite severity scale (CR-PCSS) and the patient-reported photometric cellulite severity scale (PR-PCSS) are tools that enable reliable and efficient assessment of cellulite severity. The objective of this non-intervention study was to evaluate the intra- and inter-rater reliability of the CR-PCSS and its concordance with the PR-PCSS in clinician-assessed, in-situ ("directly examined") patients.

[0157] Methods: CR-PCSS and PR-PCSS are 5-point photoquantification scales that rank cellulite severity in ascending order according to the number and depth of indentations on the assessed area: left or right buttock (buttock scale) or left or right posterolateral thigh (thigh scale), and include 5 photographs with corresponding labels (0=none, 1=almost none, 2=mild, 3=moderate, 4=severe) and textual descriptive terms. Test-retest reliability of CR-PCSS was assessed at baseline and on day 2. To minimize clinician reliance on memory, patient order was changed on day 2, and clinicians were not allowed to use visual or auditory cues or touch patients. The same patients included in the clinician assessment of CR-PCSS self-assessed cellulite severity using PR-PCSS. Either photographs or mirrors were used at baseline, and the other was used at 14 days later. The order of methods was randomly assigned. Intra-rater and inter-rater (CR-PCSS) reliability was estimated using the intraclass correlation coefficient (ICC) for agreement, and the corresponding 95% confidence interval (CI) was calculated. The concordance between CR-PCSS ratings and PR-PCSS ratings was calculated at the baseline left Alternatively, the calculation was performed on the right buttock and the left or right thigh.

[0158] Results: The six clinicians included as CR-PCSS raters were mostly male (n=5; 83.3%), had an average of 21.3 years of medical practice (ranging from 4 to 54 years), and specialized in either plastic surgery (n=3; 50%) or dermatology (n=3; 50%). The 75 patients had an average age of 44.8 years (ranging from 18 to 71 years), were mostly Caucasian (n=52; 69.3%), and the majority (n=57; 76%) self-identified as having cellulite on their thighs and buttocks. The overall mean (95% CI) ICC score estimates for intra-clinic rater reliability of CR-PCSS between baseline and day 2 were 0.81 (0.73, 0.90) and 0.81 (0.72, 0.90) for both the left and right gluteal regions, and 0.78 (0.67, 0.90) and 0.79 (0.67, 0.90) for the left and right thighs, respectively, demonstrating quarter-sectional ICC reliability. At baseline, the overall mean (95% CI) ICC score estimates for inter-clinic rater reliability in the left and right gluteal regions were 0.76 (0.69, 0.83) and 0.76 (0.68, 0.82) for both the left and right thighs, and 0.74 (0.67, 0.81) and 0.75 (0.68, 0.82) for the left and right thighs, respectively. The intra-rater and inter-rater reliability of CR-PCSS was considered acceptable across all domains, with a lower limit estimate of 0.70 or higher and an upper limit estimate of approximately 0.90 for the 95% CI. At baseline, the inter-method concordance (ICC [95% CI]) between CR-PCSS and PR-PCSS in the left and right gluteal regions was 0.51 (0.32, 0.66) and 0.56 (0.38, 0.70), respectively, and in the left and right thigh regions it was 0.61 (0.44, 0.73) and 0.67 (0.53, 0.78).

[0159] Conclusion: CR-PCSS is a reliable tool for assessing the severity of cellulite in the buttocks and thighs and correlates well with PR-PCSS.

[0160] Example 4: Phase 3 randomized, double-blind, placebo-controlled trial of EN3835 in the treatment of edematous fibrosclerosing subcutaneous adipose tissue abnormalities. Two Phase 3 randomized, double-blind, placebo-controlled trials will be conducted to assess the efficacy and safety of EN3835 in treating EFP in approximately 420 adult women in each trial. Participants will undergo eligibility screening within 14 days prior to enrollment in this study. Participants will be eligible if they have two treatment areas (both buttocks) (also known as quarters) independently assessed as having moderate or severe levels of cellulite, either using the Patient-Reported Photometric Cellulite Severity Scale (PR-PCSS) or the Clinician-Reported Photometric Cellulite Severity Scale (CR-PCSS). Buttock eligibility will be confirmed on day 1. Once buttock eligibility is confirmed, participants will be randomly assigned in a 1:1 ratio to either the treatment group (0.84 mg of EN3835 per buttock or placebo) within the clinical trial site. Each subject undergoes a treatment course consisting of three treatment sessions spaced 21 days apart (i.e., on days 1, 22, and 43). Each treatment session consists of 12 injections in each of the two buttocks (0.3 mL of EN3835 0.07 mg / injection, or placebo; 0.84 mg in 3.6 mL per buttock), for a total volume of 7.2 mL (1.68 mg). [Table 26]

[0161] Subjects, researchers, field staff, and Endo staff will not be informed of the distinction between target and non-target buttocks.

[0162] On day 71 (at the end of the study / in case of early termination), photographs of each buttock will be taken and evaluated by the subjects using PR-PCSS. The researchers will perform a live assessment of each buttock using CR-PCSS. A comprehensive assessment will be completed by both the subjects and the researchers.

[0163] The selection criteria include the following: 1. To freely sign and date the informed consent agreement. 2. Must be a woman aged 18 or older. 3. At the time of screening, the patient has two bilateral buttocks, each buttock having the following characteristics: a. A score reported as 3 or 4 (moderate or severe) by the subject (PR-PCSS), and b. A score reported as 3 or 4 (moderate or severe) by the researcher (CR-PCSS). 4.1 On the day of the examination, the patient has two bilateral buttocks, each buttock having the following: a. A score reported as 3 or 4 (moderate or severe) by the subject (PR-PCSS), and b. A score reported as 3 or 4 (moderate or severe) by the researcher (CR-PCSS).

[0164] The treatment involves administering 0.84 mg of EN3835 per buttock in 12 subcutaneous injections (0.3 mL injections per injection, divided into three 0.1 mL aliquots), to each of the two buttocks, for a total dose of 1.68 mg and a total volume of 7.2 mL (3.6 mL per buttock). The total number of injections per treatment visit is 24, administered to both buttocks. There are three treatment visits at 21-day intervals, namely on day 1, day 22, and day 43.

[0165] The investigational drug will be administered subcutaneously. As shown in Figure 7, a single cutaneous injection of the investigational drug will be administered to each injection site, A, B, and C, as three 0.1 mL aliquots (total injection volume of 0.3 mL). Eight syringes (four syringes per buttock) will be prepared for administration between each treatment visit. Each syringe will contain 0.9 mL of the investigational drug (i.e., three injections will be given from each syringe). Twelve cutaneous injections of 0.3 mL each will be administered into each of the two buttocks between each treatment visit.

[0166] As illustrated in Figure 7, drug administration at each injection site is as follows.

[0167] Needle tip position A: Position the needle perpendicular to the skin surface at the injection site at an angle of 90°, and gently push the plunger of the syringe to inject a 0.1 mL aliquot of the test drug for one dose.

[0168] Needle tip position B: Pull the needle out slightly (but not too far from the injection site), reposition it above the long axis of the depression deviated from the perpendicular by approximately 45° (but 45° or less), and gently push the plunger of the syringe to inject a 0.1 mL aliquot of the test drug for one dose.

[0169] Needle tip position C: Pull the needle out slightly (but not too far from the injection site), reposition it below the long axis of the depression deviated from the perpendicular by approximately 45° (but 45° or less), and gently push the plunger of the syringe to inject a 0.1 mL aliquot of the test drug for one dose.

[0170] Between each treatment visit, administer 12 skin injections of 0.3 mL into each of the two treated buttocks. The plane containing injection dispensing points A, B, and C should be perpendicular to the skin, and when the depression is an elongated trough-like depression, it should be perpendicular to the long axis of the depression. The subject should remain in the prone position for at least 5 minutes after treatment. During treatment visits 1, 2, and 3, record the total number of treated depressions and the total number of injections administered.

[0171] The study period shall be approximately 84 days (including the screening phase). The screening phase of the study shall be up to 14 days.

[0172] Evaluate the efficacy according to the following evaluation criteria. i. Subjects using PR-PCSS while viewing digital images of the target buttock: A 5-level scale ranging from 0 (no cellulite) to 4 (severe cellulite) for the target buttock (on day 1 (baseline) and on days 22, 43, and 71) ii. Subjects using PR-PCSS while viewing digital images of non-target buttocks: A 5-level scale ranging from 0 (no cellulite) to 4 (severe cellulite) for non-target buttocks (Day 1 (baseline) and Days 22, 43, and 71) iii. Researchers using CR-PCSS via live assessment: A 5-level scale ranging from 0 (no cellulite) to 4 (severe cellulite) for the target buttocks (at day 1 (baseline) and days 22, 43, and 71). iv. Researchers using CR-PCSS via live assessment: A 5-level scale ranging from 0 (no cellulite) to 4 (severe cellulite) for the target buttocks (at day 1 (baseline) and days 22, 43, and 71). v. Researchers using CR-PCSS via live assessment: A 5-level scale ranging from 0 (no cellulite) to 4 (severe cellulite) for non-target buttocks (at day 1 (baseline) and days 22, 43, and 71). vi. Researcher Global Aesthetic Improvement Scale (I-GAIS): A 7-level scale ranging from 3 (very good improvement) to -3 (very bad deterioration) for the target buttocks (days 22, 43, and 71). vii. Researcher Global Aesthetic Improvement Scale (I-GAIS): A 7-level scale ranging from 3 (very good improvement) to -3 (very bad deterioration) for non-target buttocks (days 22, 43, and 71). viii. Target Global Aesthetic Improvement Scale (S-GAIS): A 7-level scale ranging from 3 (very good improvement) to -3 (very bad deterioration) for the target buttocks. Ru (Days 22, 43, and 71) ix. Target Global Aesthetic Improvement Scale (S-GAIS): A 7-level scale ranging from 3 (very significant improvement) to -3 (very significant deterioration) for non-target buttocks (days 22, 43, and 71). x. Patient-Reported Cellulite Effect Scale (PR-CIS): Six questions with responses to each question, each using a numerical rating scale (NRS) ranging from 0 (not at all applicable) to 10 (very applicable). xi. Subject Self-Rating Scale (SSRS): A 7-level scale ranging from 0 (extremely dissatisfied) to 6 (extremely satisfied) (Day 1 (baseline) and Day 71) xii. Satisfaction assessment of target cellulite treatment: A 5-level scale ranging from 2 (very satisfied) to -2 (very dissatisfied) for both targeted and non-targeted buttocks (Day 71)

[0173] The primary endpoint is the proportion of two-level composite respondents on day 71, and these respondents are defined as subjects with the following characteristics: i. Improvement of at least two levels of severity from baseline (day 1 visit) in CR-PCSS, as assessed in situ by the researcher for the target gluteal region, and ii. Improvement of at least two levels of severity from baseline in PR-PCSS, as assessed by the subject while viewing digital images of the target buttocks.

[0174] A subject is considered a responder if these criteria are met in the randomized target buttock area of ​​the subject.

[0175] There are eight key secondary endpoints, which are grouped into three families of two to four endpoints each, and analyzed in a hierarchical order. ●Family #1 (4 endpoints): • Percentage of PR-PCSS responders who showed improvement of 1 level or more compared to day 1 in the PR-PCSS severity assessment of the target gluteal region on day 71. • Percentage of PR-PCSS responders who showed improvement of 2 levels or more compared to day 1 in the PR-PCSS severity assessment of the target gluteal region on day 71. • Percentage of composite responders with 1 level of severity improvement from baseline (defined as subjects with at least one level of severity improvement from baseline in CR-PCSS severity in the target buttocks, as assessed in situ by the researcher, and at least one level of severity improvement from baseline in PR-PCSS severity in the target buttocks) on day 71 compared to day 1. • Percentage of composite responders with two levels in the non-target buttocks on day 71 compared to day 1 ●Family #2 (2 endpoints): • Percentage of SSRS respondents at level 1 who were at least somewhat satisfied (SSRS rating ≥ 4) on day 71. • Change in PR-CIS total score from baseline (Day 1) on Day 71 ●Family #3 (2 endpoints): • Percentage of S-GAIS respondents who showed one level or more improvement (improvement, significant improvement, or very significant improvement) in the S-GAIS assessment of the target gluteal region on day 71. • Defined as subjects showing 2 or more levels of improvement (significant improvement or very significant improvement) in the S-GAIS assessment of the target glute on day 71, with a 2-level S-GAIS assessment. IS Respondents

[0176] Example 5: Evaluation of Durability In follow-up surveys of the Phase 2b study described above, persistence was assessed. Persistence was defined as 1) from the day the subject became a two-level composite responder to the first of two consecutive days when the assessment rating was retained at the return baseline rating, and 2) from the day the subject became a one-level composite responder to the first of two consecutive days when the assessment rating was retained at the return baseline rating.

[0177] The assessment was designed using an observation phase and a subsequent treatment phase (treatment of untreated or untreated areas) and associated observation phases. Blinded assessments (CR-PCSS and PR-PCSS) were collected for 237 subjects assessed at 6 months and 72 subjects assessed at 9 months. Of these subjects, 55 received treatment with EN3835 and showed at least one level of improvement in the control study. Of these 55 composite responders, 54 were assessed during the observation phase. Table 3 shows the breakdown of enrolled one-level and two-level composite responders. Of the 20 two-level composite responders who received active treatment and were observed in the EN3835-201 study, 19 subjects were enrolled in the EN3835-202 study. [Table 27]

[0178] The persistence of these composite respondents at 6 and 12 months in the open portion of the open observational phase of EN3835-202, and at 6 and 9 months in the blinded assessment phase, is summarized by composite responder level.

[0179] Duration of two-level composite responders The persistence of drug effects at 6 months (day 180) and 12 months (day 360) was evaluated in the EN3835-202 study in 19 and 16 composite respondents with two levels of cellulite severity, i.e., subjects who had at least two levels of improvement in cellulite severity in both PR-PCSS and CR-PCSS at day 71. Of the composite respondents with two levels of improvement, i.e., subjects who had at least two levels of improvement in cellulite severity in both PR-PCSS and CR-PCSS, 100% (n=19) and 100% (n=16) demonstrated persistence of the effect at 6 months and 12 months, respectively (i.e., no subjects returned to baseline during the two consecutive visits; see Table 4). [Table 28]

[0180] To further support the durability of the effect in two-level composite responders, the assessment of cellulite severity in the initial phase of the EN3835-202 study was performed by the researchers and the subjects, still blinding the treatment that the subjects received in the DBPC study (EN3835-201). In this blinded phase of EN3835-202, 100% of the two-level composite responders showed the sustained effect of EN3835 at the 6th month (n = 18) and the 9th month (day 270; n = 6) respectively (Table 5). [Table 29]

[0181] Durability of one-level composite responders The durability of the drug effect at the 6th month (day 180) and the 12th month (day 360) was evaluated in the ongoing non-blinded continuation study (EN3835-202 study) in 54 and 47 one-level composite responders respectively, that is, the subjects who had at least a one-level improvement in cellulite severity in both PR-PCSS and CR-PCSS on day 71. Among these composite responders, 92.6% (that is, 100% - failure rate = percentage of sustained composite responders) and 97.9% demonstrated durability at the 6th month and the 12th month respectively (that is, only 4 subjects (7.4%) and 1 subject (2.1%) returned to the baseline in two consecutive visits) (Table 6). [Table 30]

[0182] To further support the persistence of the effect in one-level composite responders, cellulite severity was assessed in the initial phase of the EN3835-202 study, with researchers and subjects still blinded to the treatments received by subjects in the DBPC study (EN3835-201). In this blinded phase of EN3835-202, 92.2% and 100% of one-level composite responders demonstrated a sustained effect of EN3835 at 6 months and 9 months (270 days), respectively, in 51 and 16 evaluable composite responders (Table 7). Blinding of the treatment was lifted when 270 days became the longest interval assessed in a blinded manner. [Table 31]

[0183] In summary, the persistence of the effect at 6 months was demonstrated in over 92% of one- or two-level composite responders in the open-label or double-blind (DB) phase of the EN3835-202 study. Persistence at 12 months was demonstrated in over 97% of one- or two-level composite responders in the open-label phase of EN3835-202. This persistence was further supported by the DB assessment at 9 months (day 270), which assessed that 100% of composite responders at this point had a continued drug effect. These results support the persistence of EN3835 in acting on cellulite for up to one year.

[0184] The embodiments of the present invention described above are intended to be illustrative only, and numerous variations and modifications will be obvious to those skilled in the art. All such variations and modifications are intended to fall within the scope of the present invention as defined in any of the accompanying claims.

[0185] The following are examples of aspects of the present invention. Item 1 A validated photometric scale for assessing the severity of cellulite in affected areas of human subjects, Images of the affected area of ​​a real patient, comprising 3 to 10 points, based on the characteristics of cellulite. The images are organized into different categories that represent the level of severity. The aforementioned features are selected from the group consisting of the number, depth, size, width, diameter, and distribution of the indentations, and A photodigital scale in which, when used by multiple users, at least 40% assign the areas of cellulite in question to the same severity level. Section 2 The scale described in item 1, wherein the affected area is the buttocks. Section 3 The scale described in item 1, wherein the severity level of the aforementioned feature is represented by photographs of at least three different real-world human subjects. Section 4 The scale described in item 1, which includes five images representing five different categories. Section 5 The scale according to item 1, wherein the user is a clinician and provides the same severity level in at least 50% of the patients. Section 6 The scale described in item 1, wherein the affected area is the thigh. Section 7 The aforementioned images correspond to the scales for the buttocks and thighs shown in Figures 2-5, as described in Section 1. Section 8 The scales described in Section 1, including the CR-PCSS scale. Section 9 The scales described in Section 1, including the PR-PCSS scale. Section 10 The scale according to paragraph 8, wherein, when used by multiple users, at least 40% assign the areas of cellulite in question to the same severity level. Section 11 The scale according to paragraph 9, wherein, when used by multiple users, at least 40% assign the areas of cellulite in question to the same severity level. Section 12 A method for assessing the severity of cellulite in the affected area of ​​a human subject, a. Select the affected area, b. A method comprising classifying the severity of the cellulite in question into at least five classes of increasing severity using images. Section 13 The method according to paragraph 12, wherein the affected area is the thigh or buttocks. Section 14 The aforementioned images are relative to the scales of the buttocks and thighs shown in Figures 2-5, and the method is as follows: a. Identifying the image that most closely resembles the appearance of the affected area on the thigh or buttocks, b. Reading the numbers corresponding to the identified image, c. Further including identifying the label that is most suitable for the affected area of ​​the thigh or buttocks, or the affected area of ​​the thigh or buttocks, The method described in paragraph 12, wherein using the scale results in consistency among at least 50% of the evaluators. Section 15 A method for assessing the severity of cellulite in human subjects, a. Select the affected area to be evaluated, b. The affected area is represented by a series of 3 to 10 images, each having a number indicating the level of severity. Comparing and c. Identifying the image that most closely resembles the appearance of the affected area, d. Reading a number corresponding to the identified image for assigning a severity level, A method by which the aforementioned scale is used to ensure consistency among at least 50% of multiple users. Section 16 The method according to paragraph 15, wherein the CR-PCSS scale is used by multiple clinicians, and at least 40% of the clinicians give the same cellulite severity rating to the area of ​​cellulite in the patient when the patient is screened and from day 1 before treatment. Section 17 The method according to paragraph 15, wherein the clinician provides such same rating to about 50%, or about 60%, or about 70%, or about 80%, or about 90%, or about 100% of the patients. Section 18 The method according to item 15, wherein CR-PCSS and PR-PCSS are used to assess the severity of cellulite by an evaluation method selected from the group consisting of live assessment by viewing digital images of the cellulite area, live assessment by viewing photographs of the cellulite area, and live assessment by viewing mirror images of the cellulite area. Section 19 A method for assessing the severity of cellulite in the buttocks or thighs of a human subject, comprising: providing a validated scale including 3 to 10 photographs, illustrations, or models representing the area of ​​the buttocks or thighs of a human, wherein the photographs, illustrations, or models are organized into different categories representing levels of severity based on cellulite features, and the features are selected from a group consisting of the number and depth of depressions; and comparing the scale to the corresponding features of the subject to obtain an assessment of the cellulite severity level of the subject. Section 20 The method described in Section 19, including the CR-PCSS scale. Section 21 The method described in Section 19, including the PR-PCSS scale. Section 22 The method described in item 19, wherein both the CR-PCSS scale and the PR-PCSS scale are used to assess severity. Section 23 A method for assessing the severity of cellulite on the thighs in human subjects, a. To assess the quarter of the thigh surface of the subject showing signs of cellulite, b. Assessing the severity of the cellulite in the subject, including using the CR-PCSS scale, c. Using images, classifying the severity of the cellulite in the subject into at least five classes of increasing severity, wherein the lowest class (0) means no depressions or raised areas, class 1 means a few depressions or ridges that are mostly superficial in depth, class 2 means several ridges that are shallow in depth with some raised areas, class 3 means numerous ridges that are mostly moderate in depth with alternating raised and depressed areas, and class 4 means many ridges that are some more severe in depth with alternating raised and depressed areas. Methods that include... Section 24 A method for assessing the severity of cellulite on the thighs in human subjects, a. To assess the quarter of the thigh surface of the subject showing signs of cellulite, b. Assessing the severity of cellulite in the subject, including using the PR-PCSS scale, c. Using images, classifying the severity of the cellulite in the subject into at least five classes of increasing severity, wherein the lowest class (0) means no obvious cellulite, class 1 means a few superficial depressions or ridges, class 2 means several mostly superficial depressions or ridges, class 3 means many mostly somewhat deep depressions or ridges, and class 4 means many deep depressions or ridges covering most of the skin area. Methods that include... Section 25 A method for assessing the severity of cellulite on the buttocks in human subjects, a. To assess the quarter of the buttock surface of the subject showing signs of cellulite, b. Assessing the severity of the cellulite in the subject, including using the PR-PCSS scale, c. A method comprising classifying the severity of the cellulite in the subject into at least five classes of increasing severity, wherein classification to the lowest class (0) means no obvious cellulite, classification to class 1 means a few superficial depressions or ridges, classification to class 2 means several mostly superficial depressions or ridges, classification to class 3 means a number of mostly somewhat deep depressions or ridges, and classification to class 4 means a number of deep depressions or ridges covering most of the skin area. Section 26 A method for assessing the severity of cellulite on the buttocks in human subjects, a. To assess the quarter of the buttock surface of the subject showing signs of cellulite, b. Assessing the severity of cellulite in the subject, including using the CR-PCSS scale, c. A method comprising classifying the severity of the cellulite in the subject into at least five classes of increasing severity, wherein classification to the lowest class (0) means no indentations or obvious cellulite, classification to class 1 means a few indentations that are mostly superficial in depth, classification to class 2 means several indentations that are mostly shallow in depth, classification to class 3 means a number of indentations that are mostly moderate in depth, and classification to class 4 means a number of indentations that are mostly more severe in depth. Section 27 A method for treating cellulite in a human patient requiring treatment for cellulite, comprising: (a) providing a pharmaceutical formulation comprising a mixture of collagenase I and collagenase II obtained from or derived from Clostridium histolyticum, having a specific activity of about 5,000 ABC units / mg to 25,000 ABC units / mg; and (b) injecting the pharmaceutical formulation into the collagenous septal network of cellulite at a dose of about 0.1 mg to 5 mg, wherein the patient has an improvement of 2 points or more from baseline in CR-PCSS at 71 days post-treatment. Section 28 The method according to paragraph 27, wherein the improvement of 2 points or more from baseline on day 71 occurs for both the CR-PCSS and PR-PCSS scales. Section 29 The method according to item 27, wherein at 71 days post-treatment, there is an improvement of 1 point or more from baseline in both CR-PCSS and PR-PCSS. Section 30 The method according to paragraph 27, wherein the improvement of 2 points or more occurs approximately 6 months or approximately 12 months after treatment with either or both of the CR-PCSS and PR-PCSS. Section 31 The method according to item 27, wherein an improvement of 2 points or more from baseline is observed in both the CR-PCSS score and the PR-PCSS score approximately 22, 43, 90, or 180 days after treatment. Section 32 The method according to claim 27, wherein the mixture of collagenases I and II is present in a ratio of approximately 1:1. Item 33 The method according to item 32, wherein the mixture has a specific activity of about 10,000 ABC units / 0.58 mg and is administered in a dose of about 0.84 mg. Section 34 The method according to claim 33, wherein the aforementioned dose is administered by one or more injections. Section 35 The method according to item 33, wherein the aforementioned dose is administered by approximately 12 injections. Section 36 The method according to item 27, wherein the dose is approximately 0.48 to 0.84 mg of collagenases I and II present in a ratio of approximately 1:1 and having a specific activity of approximately 10,000 ABC units / mg. Section 37 The method according to claim 36, wherein the mixture is administered in one or more treatment sessions. Section 38 The method according to item 37, wherein the mixture is administered in three treatment sessions spaced approximately 15 to 30 days apart.

Claims

1. A pharmaceutical formulation for treating cellulite in human patients, wherein the pharmaceutical formulation comprises a mixture of collagenase I and collagenase II obtained from or derived from Clostridium histolyticum, the mixture having a specific activity of about 5,000 ABC units / mg to 25,000 ABC units / mg, the pharmaceutical formulation is injected into the collagenous septal network of cellulite at a dose of about 0.1 mg to 5 mg, thereby causing the patient to have an improvement of 2 points or more from baseline on the CR-PCSS at 71 days post-treatment, and the human patient has cellulite as measured using a validated photodigital scale. A photodigital scale, which has been assessed and validated for severity, includes 3 to 10 images showing affected areas of one or more real patients, where each of the 3 to 10 images of a real patient corresponds to the location of the affected area in a human subject, and each of the 3 to 10 images has a different severity rating, including numerical, descriptive, or both, where the severity rating is based on a combination of two or more cellulite features selected from groups consisting of the number, depth, size, width, diameter, and distribution of depressions, and the photodigital scale has been validated using test-retest reliability analysis for pharmaceutical formulations.

2. The pharmaceutical formulation according to claim 1, wherein the improvement of 2 points or more from baseline on day 71 occurs in both the CR-PCSS and PR-PCSS scales.

3. The pharmaceutical formulation according to claim 1, wherein on day 71 after treatment, there is an improvement of 1 point or more from baseline in both the CR-PCSS and PR-PCSS.

4. The pharmaceutical formulation according to claim 1, wherein the improvement of 2 points or more occurs approximately 6 months or 12 months after treatment by either or both of the CR-PCSS and PR-PCSS.

5. The pharmaceutical formulation according to claim 1, wherein approximately 22, 43, 90, or 180 days after treatment, there is an improvement of 2 points or more from baseline in both the CR-PCSS score and the PR-PCSS score.

6. The pharmaceutical formulation according to claim 1, wherein the mixture of collagenases I and II is present in a ratio of approximately 1:

1.

7. The pharmaceutical formulation according to claim 6, wherein the mixture has a specific activity of about 10,000 ABC units / 0.58 mg and is administered in a dose of about 0.84 mg.

8. The pharmaceutical preparation according to claim 7, wherein the aforementioned dose is administered by one or more injections.

9. The pharmaceutical preparation according to claim 7, wherein the aforementioned dose is administered by approximately 12 injections.

10. The pharmaceutical formulation according to claim 1, wherein the aforementioned dose is approximately 0.48 to approximately 0.84 mg of collagenase I and II, present in a ratio of approximately 1:1 and having a specific activity of approximately 10,000 ABC units / mg.

11. The pharmaceutical formulation according to claim 10, wherein the mixture is administered in one or more treatment sessions.

12. The pharmaceutical formulation according to claim 11, wherein the mixture is administered in three treatment sessions spaced approximately 15 to 30 days apart.

Images