HIV-Associated Lipoatrophy

The complete syndrome of HIV-associated lipodystrophy consists of lipoatrophy of the face and extremities, truncal obesity with the development of a buffalo hump, triglyceridemia, and insulin resistance.
The cause is multifactorial. It is associated with treatment with nucleoside reverse transcriptase inhibitors (NRTIs), notably stavudine (Zerit®) and with protease inhibitors. In addition, host factors play a role, in that white patients with CD4 counts less than 100 cells/mm³ and body mass index less than 24 kg/m² have a significant risk of developing lipoatrophy independently of HIV medications.
Facial lipoatrophy is a marker of a person who is infected with HIV, and causes severe psychological problems and depression in many of them, even when the treatment has lowered the viral load to undetectable levels.

Lesions are usually asymptomatic.
There is loss of facial fat to varying degrees.
In severe cases, there is hollowing of the cheeks and development of a “nasolabial band” between the nasolabial lines and the cheeks (Fig. 33.20). Loss of the temporal, periorbital, and the fat of the cheeks gives prominence to the underlying bony structure, giving a skeletal look.

Distribution of Lesions

Initially the cheeks are affected.
Later the temporal and the periorbital fat disappears.

Management

Avoidance of NRTIs, especially stavudine.
Careful selection of protease inhibitors. Atazanavir (Reyataz®) does not cause the same lipid abnormalities or body fat changes that some of the other protease inhibitors do.
Switching therapy may stop the progression of lipoatrophy.
Filler substances have been used successfully to treat facial lipoatrophy and to reduce the stigma that is felt by patients with HIV infection. In the United States, poly-L-lactic acid (Sculptra®) and calcium hydroxylapatite microspheres (Radiesse®) are currently approved for the treatment of HIV-associated lipoatrophy. There are many more filler substances being used in other countries for this indication.
Treatment of patients with severe lipoatrophy with Sculptra® requires an average of 6 treatments over 6 months by a skilled injector to achieve good results, which last for an average of 2 years. Results are not immediate, but develop 4 to 6 weeks after injection as the skin begins to form new collagen on the poly-L-lactic acid matrix.
Treatment with Radiesse® does result in immediate correction, and may require only a single treatment. The microspheres which contain the calcium provide a matrix on which new collagen is formed by the skin. Because the reabsorption of the microspheres may occur more rapidly than new collagen formation, a touch-up treatment may be required approximately 3 months after the initial treatment. Results last for a year or more.
When lipoatrophy is treated by a skilled injector, side effects are rare.

Points to Remember

NRTIs and protease inhibitors are the main causes of facial lipoatrophy.
Patients with HIV are extremely stressed by facial lipoatropy.
Facial lipoatrophy can be treated with injections of poly-L-lactic acid or calcium hydroxylapatite microspheres.

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