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Insulin induced lipodystrophy

Lipoatrophy is becoming less common with the advent of newer insulin analogues; however, lipohypertrophy is still prevalent.

What to know?

Lipodystrophies are a heterogeneous group of disorders characterised by abnormal distribution of body fat which can be genetic or acquired and also can have a generalised distribution or a more localised (partial) distribution. Insulin induced lipo- dystrophy is an acquired partial lipodystrophy. Lipohypertrophy and lipoatrophy are two main inter-related but distinct dermatological complications of subcutaneous insulin injections. Of these, lipohypertrophy is a much more common complication than lipoatrophy.

Insulin induced lipoatrophy and, more commonly, lipohypertrophy are dermatological complications of insulin therapy.

Insulin absorption from these sites is unpredictable and can lead to erratic glycaemic levels and unpredictable hypoglycaemic attacks.2,12 When large areas are involved, it can be cosmetically unsightly and socially embarrassing for patients.

Preventive and therapeutic strategies

Rotation of injection sites with each injection and non-reuse of needles. Topical dexamethasone injections have been tried for the management of insulin induced lipoatrophy.

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Causes

This complication occurs because of repeated injections at the same site. As these areas are relatively painless, patients tend to inject in the same area again and again rather than move to a new painful site. Other possible risk factors associated are type 1 diabetes due to longer duration of insulin therapy, high number of insulin injections, reuse of needles with a significant increase if used more than five times and use of pen devices. Development of insulin antibodies is also suggested as a possible underlying mechanism.

Management

Injection sites should be examined at least annually by a health care professional for possible lipohypertrophy or lipo- atrophy.

Changing insulin to rapid acting humanised insulin has been shown to decrease this side effect as adipocytes are in contact with insulin for short periods and thus local lipogenic effects are minimised.20 If conservative steps fail, then liposuction is an effective alternative.

Examine your own injection sites and how to detect lipohypertrophy.

Changing injection sites helps in preventing development of lipohypertrophy

Changing or rotating the site of insulin injection and changing type of insulin were traditional approaches to prevent further lipoatrophy. Switching to CSII2,12 and/or short acting insulin analogues are alternative methods. These lesions can sometimes spontaneously regress, but use of small amounts of dexamethasone along with insulin injections was found to be beneficial.

Patients should be taught self examination for early recognition of skin changes and to avoid these areas

Do not to inject into areas of lipohypertrophy until abnormal tissue returns to normal, which will take several months or even years

Patients should be educated regarding proper injection techniques and rotating injection sites

Reference:

Kadiyala, P., Walton, S., & Sathyapalan, T. (2014). Insulin induced lipodystrophy. British Journal of Diabetes, 14(4), 131-133.