How is gluteal lipohypertrophy managed?

Management of Gluteal Lipohypertrophy

Immediately cease all insulin injections into the affected gluteal area and rotate to normal tissue sites, while reducing insulin doses by at least 20% to prevent hypoglycemia during the transition. 1

Immediate Management Steps

Stop Injecting into Affected Areas

• Patients must completely avoid injecting into areas of lipohypertrophy until resolution occurs, as insulin absorption from these sites is erratic and unpredictable, leading to hyperglycemia, unexpected hypoglycemia, and increased glucose variability. 1
• Mark the edges of the lipohypertrophy with a single-use skin-safe marker (with patient consent) to allow measurement and tracking of improvement over time. 1
• Photograph visible lesions for documentation and future comparison. 1

Adjust Insulin Dosing

• Reduce insulin doses by more than 20% when switching from lipohypertrophic sites to normal tissue, as absorption will be significantly more predictable and efficient from healthy tissue. 1
• The exact reduction varies individually and must be guided by frequent blood glucose monitoring. 1
• Patients switching away from lipohypertrophy are at high risk for hypoglycemia if doses are not reduced appropriately. 1

Prevention Strategies Going Forward

Systematic Site Rotation

• Implement regular, systematic rotation of insulin delivery sites both between anatomical areas (abdomen, thighs, buttocks, upper arms) and within each site. 1
• Inject at least 1 cm away from previous injection sites. 2
• Use injection site map handouts or rotation apps to encourage adherence to proper rotation schedules. 1

Optimize Injection Technique

• Use the shortest needles available (4-mm pen needles) for all patients regardless of body habitus, as these are effective and reduce risk of intramuscular injection. 1
• Avoid injecting cold insulin directly from the refrigerator, as this contributes to lipodystrophy development. 2
• Never reuse needles, as needle reuse is associated with increased lipohypertrophy risk. 1

Monitoring and Follow-Up

Regular Clinical Assessment

• Healthcare providers must examine injection sites visually and by palpation at minimum once yearly, or more frequently if lipohypertrophy is already present. 1
• Palpation is often more sensitive than visual inspection for detecting lipohypertrophy; use lubricating gel to facilitate examination. 1
• Ideally perform examination with patient lying down and disrobed to underwear, though sitting, standing, or partially clothed examination is acceptable when necessary. 1

Patient Education

• Teach patients to inspect their own injection sites and recognize early signs of lipohypertrophy (soft, smooth raised areas several centimeters in breadth). 1
• Provide training on proper site rotation, injection technique, and prevention strategies. 1
• Assess injection device use and technique as part of comprehensive diabetes care. 1

Expected Outcomes and Timeline

• Lipohypertrophy typically regresses after stopping insulin injections into the affected areas, though the timeline varies by individual. 1
• Continue monitoring the marked areas at follow-up visits to document improvement. 1
• If lipohypertrophy does not regress despite avoiding the site, consider the rare possibility of localized amyloidosis, which requires biopsy for diagnosis and does not resolve with site avoidance alone. 1

Refractory Cases

• In severe cases that do not respond to conservative management (site avoidance), liposuction surgery has been reported as a successful treatment option. 3
• Some case reports suggest switching to faster-acting insulin analogues (such as insulin lispro) may help in susceptible individuals, though this is based on limited evidence. 4

Critical Pitfalls to Avoid

• Do not underestimate the clinical significance of lipohypertrophy—it is not merely cosmetic but directly impacts glycemic control, insulin requirements, and hypoglycemia risk. 5, 6
• Simply asking patients if they rotate sites is insufficient; physical examination with palpation is mandatory. 1
• Failing to reduce insulin doses when switching away from lipohypertrophic sites can result in severe hypoglycemia. 1