Insulin induced lipoatrophy has become a relatively rare complication of subcutaneous insulin injection with the use of recombinant human insulin.

A 23 year old female with Type 1 Diabetes Mellitus for 13 years developed bilateral localized areas of painful lipoatrophy around 12-15 cm diameter on the abdomen. They began spontaneously without an obvious trigger in injection sites and rapidly progressed with the loss of subcutaneous fat over three weeks in June 2013. They were associated with worsening glycaemic control and multiple episodes of nocturnal hypoglycaemia.

Insulin aspart (Novorapid) and glargine (Lantus) had been injection on opposite site of the abdomen for three years. She had an extensive history of allergy to dairy, animals, anaphylaxis to glulisine insulin and failed Continuous Subcutaneous Insulin Infusion after a year because of allergy to adhesives used to fix the giving set to the skin.  Biopsy of the lesion revealed nonspecific deeply infiltrating inflammatory changes in a perivascular distribution with no evidence of lupus or morphea.  Immunological testing revealed raised insulin antibodies (5 IU/L, normal <1).

A trial of various concentrations of dexamethasone mixed with Novorapid  injected subcutaneously around the site of lipoatrophy was of little benefit over three months, and weight increased and glycaemic control worsened. She was intolerant of a trial of azathioprine.

The patient was referred to Westmead Hospital, Sydney where intraperitoneal delivery of insulin ('Insuman' Infusat) via the Roche Diaport system commenced August 2014. Glycaemic control improved along with a significant reduction in insulin requirements, and some improvement in the size of the area of lipoatrophy on one side of the abdomen. Unfortunately, she continued to have problems with recurrent cellulitis around the Diaport site requiring courses of oral antibiotics and finally the port occluded after nine months and had to be removed. At present the patient is waiting to have another Diaport system fitted. 

The Roche Diaport should be considered in patients with insulin allergy and painful lipoatrophy. Since insulin is absorbed through the peritoneum into the portal circulation within a few minutes the process is not thought to activate the cutaneous inflammatory cytokines responsible for painful lipoatrophy.