Hyaluronic Acid Treatment of Facial Fat Atrophy in HIV-positive Patients

H Bugge; A Negaard; L Skeie; B Bergersen

Disclosures

HIV Medicine. 2007;8(8):475-482. 

In This Article

Abstract and Introduction

Objectives: Facial lipoatrophy can be devastating for HIV-infected patients, with negative effects on self-esteem. In this study, we treated facial fat atrophy in the nasogenian area with hyaluronic acid (Restylane SubQ; Q-Med AB, Uppsala, Sweden).
Methods: Twenty patients were included in the study. Treatment effects were evaluated at baseline, and at weeks 6, 24 and 52 using ultrasound, the Global Aesthetic Improvement Scale, the Visual Analogue Scale and the Rosenberg Self-Esteem Scale.
Results: Mean (±standard deviation) total cutaneous thickness increased from 6±1 mm at baseline to 15±3 mm at week 6 (P<0.001), and declined to 10±2 mm at week 52 (P<0.001 vs baseline). The response rate (total cutaneous thickness >10 mm) was 100% at week 6, 85% at week 24 and 60% at week 52. At week 6, all of the patients classified their facial appearance as very much improved or moderately improved. They also reported increased satisfaction with their facial appearance and had higher self-esteem scores. At week 52, 15 of 19 patients still classified their facial appearance as very much improved or moderately improved, although the mean total cutaneous thickness had gradually declined.
Conclusions: Our results indicate that Restylane SubQ is a useful and well-tolerated dermal filler for treating HIV-positive patients with facial lipoatrophy.

Facial fat atrophy is a known adverse event in HIV-positive patients on antiretroviral therapy. Facial fat atrophy can negatively impact patients' quality of life and may contribute to a reduction in patient adherence to antiretroviral therapy.[1] It has been reported that affected patients encounter stigmatization as a result of facial lipoatrophy which can in turn erode self-esteem.[2] Treatment strategies include switching antiretroviral regimens, prescription of medication, insertion of surgical implants and injection of dermal fillers.

Switching away from thymidine analogues has been shown to have only a modest effect on the recovery of subcutaneous fat mass. A follow-up study of the Oslo HIV Cohort Study 2000 found that facial atrophy was less reversible than fat atrophy of the extremities.[3] Although pioglitazone (a new antidiabetic drug)[4] has recently been shown to have an effect on limb lipoatrophy in HIV-infected patients, the specific effect of pioglitazone and similar drugs on facial lipoatrophy is not documented.

Injection of soft-tissue fillers appears to be the simplest way to correct facial lipoatrophy. There are numerous soft-tissue fillers, and they can be divided into two main categories: nonpermanent and permanent fillers. Nonpermanent fillers are also known as temporary or reabsorbable fillers and include polylactic acid, collagen, and calcium hydroxyapatite. Injectable silicone, polymethylmethacrylate microspheres and polyacrylamide gel are permanent fillers. Injected autologous fat can be nonpermanent or permanent. Injectable hyaluronic acid derivatives are the most commonly used reabsorbable dermal fillers for soft-tissue augmentation today,[5] and have replaced collagen as the standard injection material.[6] However, there are no long-term studies on the treatment of HIV-related lipoatrophy with hyaluronic acid.

Hyaluronic acid products have been demonstrated to have a good safety profile, and few complications have been reported after the product was improved.[7,8] The hyaluronic acid product Restylane (Q-Med AB, Uppsala, Sweden) is produced from a hyaluronic acid preparation obtained by bacterial fermentation. The use of a nonanimal source is thought to reduce the likelihood of antigenic contamination and subsequent hypersensitivity reactions. Restylane received approval by the Food and Drug Administration in 2003.[7] The new Restylane product Restylane SubQ was introduced in September 2004. The main difference between Restylane SubQ and other Restylane products is the size of the gel particles and the intended level of injection. Restylane SubQ has fewer gel particles (1000 gel particles/mL) and thus larger droplets than other Restylane products, and is therefore more viscous. SubQ can therefore be injected in larger amounts and into deeper skin layers.[9]

The main aim of this study was to evaluate the efficacy, safety and durability of the new Restylane product SubQ in the correction of facial lipoatrophy in HIV-infected patients.

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