eMedicine Specialties > Dermatology > Diseases of the Subcutaneous Tissue

Lipodystrophy, HIV: Treatment & Medication

Author: David T Robles, MD, PhD, Dermatologist, Kaiser Permanente Southern California
Coauthor(s): Jonathan M Olson, BS, University of Washington School of Medicine; Roy M Colven, MD, Associate Professor of Medicine (Dermatology), University of Washington School of Medicine; Section Head of Dermatology, Harborview Medical Center; Attending Physician, Department of Dermatology, Harborview Medical Center, Madison and Medical Specialties Clinics
Contributor Information and Disclosures

Updated: Dec 8, 2008

Treatment

Medical Care

No specific medical treatment exists for HIV lipodystrophy. Lipodystrophy is often progressive and, in limited cases, may regress after the withdrawal of PI therapy. Withdrawal of thymidine analogues has shown to be effective for reversing lipoatrophy. Treatment of the underlying metabolic derangements of glucose and lipid metabolism is necessary. The evaluation and management of glucose intolerance, diabetes, and hyperlipidemia are discussed elsewhere (see Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Hypercholesterolemia, Polygenic; and Hypertriglyceridemia)

  • For the treatment of hyperlipidemia, fibrates and/or 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, as well as DHEA alone, improve the lipid profile.
  • For treatment of hyperglycemia, metformin, insulinlike growth factor-1, and DHEA improve glycemic control.
  • In some studies, treatment with rosiglitazone resulted in positive effects on lipoatrophy, insulin sensitivity, and metabolic indices of HIV-infected patients with lipoatrophy and insulin resistance. Other studies have yielded conflicting results.15

Surgical Care

  • Lipohypertrophy: The effects of treatment with liposuction or lipectomy are variable, and recurrence is common. Fat harvested during liposuction of the dorsocervical fat pad can be used for autologous fat transfer to facial areas exhibiting lipoatrophy. Facial fat grafting is further addressed in Facial Fat Grafting.
  • Lipoatrophy: Free flaps, lipotransfer, or commercial fillers or implants can be used to replace adipose tissue. Poly-L-lactic acid (Sculptra) has been used as a semipermanent injectable filler in these patients. Sculptra is approved by the US Food and Drug Administration for the treatment of facial lipoatrophy in HIV-positive patients. Calcium hydroxylapatite (Radiesse) is a soft-tissue filler consisting of 30% calcium hydroxylapatite microspheres and 30% carboxylmethylcellulose and is also approved for the treatment of facial lipoatrophy in HIV-positive patients. Other filler options include injectable bovine and human collagens, hyaluronic acid, and autologous free fat transfer. See Soft Tissue Implants for more information. 

Consultations

  • Dermatologist: This consultation can be useful for an evaluation of the underlying causes of lipodystrophy and for consideration of surgical options. Plastic surgeons also may be considered for fillers, fat transfers, and liposuction.
  • Internal medicine or endocrinology specialist: These consultations help for an evaluation of the underlying causes of lipodystrophy and for the management of hyperlipidemia and hyperglycemia.
  • Infectious diseases specialist: Consultation is useful for the management of HIV infection.
  • Psychiatrist or psychologist: A referral to one of these specialists may be necessary because of the psychological impact of body shape changes. See Further Outpatient Care.

Diet

  • No specific diet regimen is used in the management of HIV-associated lipodystrophy. Adequate nutrition and exercise may result in modest improvement in lipodystrophy and improve central obesity.
  • A balanced low-fat, low-carbohydrate diet is preferable when hypertriglyceridemia is present.

Activity

  • Exercise has been proven to improve insulin sensitivity.
  • One study showed that progressive resistance training with an aerobic component may reduce trunk fat mass.16

Medication

  • No specific medical therapy for HIV-associated lipodystrophy has proven to be beneficial.
  • An improvement of lipohypertrophy and/or lipoatrophy in individuals treated with human growth hormone, anabolic steroids, naltrexone, and a combination DHEA and cyclo-oxygenase inhibitor has been reported in some cases.
  • Pharmacotherapy aimed at managing glucose and/or lipid abnormalities associated with HIV lipodystrophy is important to reduce morbidity and prevent complications. 
More detailed approaches to address the metabolic derangements associated with HIV lipodystrophy syndrome can be found in Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; and Hypertriglyceridemia.

Dermal Filler


Poly-L-lactic acid (Sculpura)

Preparation of poly-L-lactic acid particles that are injected into the superficial subdermis, where a fibrous response is elicited.

Adult

Each carton contains 2 vials, which can be stored at room temperature

Pediatric

Not established

Documented hypersensitivity to any components

Pregnancy
Precautions

Most common adverse effects are redness, bruising, or swelling; do not inject in areas with active skin infection or inflammation; avoid injection into blood vessels; delayed occurrence of subcutaneous nodules reported; long-term safety and effectiveness beyond 2 y not investigated; safety during pregnancy, breastfeeding, or in patients <18 y not established


Calcium hydroxylapatite (Radiesse)

Susp of calcium hydroxylapatite (CaHA) microspheres.

Adult

Prepackaged, sterilized 1.3-mL syringe

Pediatric

Not established

Patients who are using medications that can prolong bleeding (eg, aspirin, warfarin, certain vitamins and supplements) may experience increased bruising or bleeding at injection site

Severe allergies, a history of anaphylaxis, or history or presence of multiple severe allergies or hypersensitivity to any ingredients

Pregnancy
Precautions

Most common adverse effects are redness, bruising, or swelling; do not inject in areas with active skin infection or inflammation; avoid injection into blood vessels; microspheres can be seen on radiographs and CT scans; safety during pregnancy, breastfeeding, or in patients <18 y not established.

More on Lipodystrophy, HIV

Overview: Lipodystrophy, HIV
Differential Diagnoses & Workup: Lipodystrophy, HIV
Treatment & Medication: Lipodystrophy, HIV
Follow-up: Lipodystrophy, HIV
Multimedia: Lipodystrophy, HIV
References
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Further Reading

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Keywords

lipohypertrophy, lipoatrophy, lipodystrophy, human immunodeficiency virus, HIV, antiretroviral medication, protease inhibitor, highly active antiretroviral therapy, HAART

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Contributor Information and Disclosures

Author

David T Robles, MD, PhD, Dermatologist, Kaiser Permanente Southern California
David T Robles, MD, PhD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Jonathan M Olson, BS, University of Washington School of Medicine
Disclosure: Nothing to disclose.

Roy M Colven, MD, Associate Professor of Medicine (Dermatology), University of Washington School of Medicine; Section Head of Dermatology, Harborview Medical Center; Attending Physician, Department of Dermatology, Harborview Medical Center, Madison and Medical Specialties Clinics
Roy M Colven, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Telemedicine Association, Phi Beta Kappa, and Washington State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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