DermatologyTier 2Disease (DEADMAN)

Cutaneous manifestations of adverse effects of therapeutic interventions - lipoatrophy

Description

Lipoatrophy - localised loss of subcutaneous fat, a recognised cutaneous adverse effect of several therapeutic interventions - classically insulin injection sites (with repeated injection at the same site) and, historically, certain older antiretroviral drug classes (particularly older nucleoside reverse transcriptase inhibitors)

Insulin-related lipoatrophy has become less common with modern purified/human/analogue insulins compared with older, less purified formulations, though it still occurs, particularly with site overuse

Insulin lipoatrophy - thought to be an immune-mediated local reaction to repeated insulin exposure at the same injection site, causing localised subcutaneous fat loss (distinct from lipohypertrophy, a much more common complication from repeated injection at the same site causing fat accumulation/thickening rather than loss)
Antiretroviral-associated lipoatrophy (particularly with older thymidine analogue NRTIs - stavudine, zidovudine) reflects mitochondrial toxicity in adipocytes, part of the broader antiretroviral-associated lipodystrophy syndrome (fat redistribution - peripheral loss with central/visceral gain)

Clinical diagnosis - localised, depressed, indented skin at the affected site, correlating with the history of repeated drug administration at that location

Injection site rotation is the primary preventive strategy for insulin-related lipoatrophy/lipohypertrophy - patient education on systematic site rotation should be routine, not just reactive once a problem develops
Antiretroviral-associated lipoatrophy is managed by switching away from the causative older drug class where clinically appropriate (given modern regimens generally avoid the most strongly implicated agents) - established fat loss does not reliably reverse even after switching, though further progression is halted

Lipohypertrophy (the more common, opposite insulin injection site complication - fat accumulation, also causing erratic insulin absorption), antiretroviral-associated lipodystrophy syndrome, insulin injection technique

Insulin lipoatrophy (fat loss) and lipohypertrophy (fat accumulation) are distinct, sometimes confused complications of the same underlying behaviour (repeated same-site injection) - both are managed by the same preventive strategy (site rotation), and lipohypertrophy specifically also causes erratic, unpredictable insulin absorption relevant to glycaemic control

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