HIV-associated facial lipoatrophy is a condition in which people living with HIV lose fat in their faces. This can make cheeks look hollow, temples appear sunken, or the jawline become more prominent. While fat loss can affect different parts of the body, facial changes are especially noticeable and can be hard on a person’s self-esteem. In this article, we will explain what HIV-associated facial lipoatrophy is, describe its different forms, list twenty possible causes, detail fifteen common signs, and review twenty ways doctors check for it.
HIV-associated facial lipoatrophy is a form of lipodystrophy seen in people living with HIV that leads to the loss of the small fat cells under the skin of the cheeks, temples, and around the eyes. Over weeks to months, the cheeks appear sunken, the temples hollowed, and the skin may become thin and wrinkled, leaving a gaunt, aged appearance. This change is distressing both cosmetically and psychologically, often contributing to social stigma and reduced quality of life PubMedNCBI.
Pathophysiologically, HIV-associated lipoatrophy arises primarily from mitochondrial damage in adipocytes (fat cells) caused by certain antiretroviral drugs—especially thymidine analogues such as stavudine and zidovudine—and, to a lesser extent, from chronic inflammation driven by the virus itself. Mitochondrial injury leads to adipocyte apoptosis (cell death) and impaired fat storage, manifesting visibly as facial hollowing PubMed.
Pathophysiology
HIV-associated facial lipoatrophy is fat loss from the face linked to either the HIV virus itself or the drugs used to treat it. In lipoatrophy, fat cells shrink or die. This leaves less padding under the skin and makes bones and muscles more visible.
Interaction with HIV: The HIV virus can cause chronic inflammation. Over time, inflammation affects how fat cells work. Fat cells may stop storing fat or may die sooner than they should.
Impact of Antiretroviral Therapy (ART): Some older ART drugs, especially thymidine analogues like stavudine and zidovudine, harm mitochondria (the energy centers of cells). When mitochondria fail, fat cells cannot stay healthy. This leads to their shrinkage or death.
Mitochondrial Toxicity: Mitochondria help cells produce energy. When certain ART drugs damage mitochondria, cells—including fat cells—lose energy and function poorly. Fat cells then drop in number, leading to visible fat loss.
Chronic Immune Activation: HIV keeps the immune system turned on. This constant activation releases chemicals called cytokines that can hasten fat cell breakdown.
Metabolic Changes: HIV and some ART drugs can change how the body handles sugars and fats. These shifts can reduce fat storage.
Because face fat is lost unevenly, people may see visible hollowing in temples, cheeks, or around the eyes. These changes often begin slowly but can become more obvious over months or years.
Types of HIV-Associated Facial Lipoatrophy
Facial lipoatrophy can appear in different patterns and severities. Doctors often use these categories to describe what they see and guide treatment.
Localized Cheek Lipoatrophy
Description: Fat loss focused on the upper and mid-cheek area.
Appearance: Sunken cheeks, hollows below the cheekbones.
Impact: May make a person look gaunt or tired without affecting other facial regions.
Temporal Hollowing
Description: Fat loss around the temples (sides of the forehead).
Appearance: Deep grooves above the ears and near the hairline.
Impact: Creates a “skull-like” look at the sides of the head.
Periorbital Lipoatrophy
Description: Fat loss around the eyes.
Appearance: Eyes appear more prominent; tear troughs deepen.
Impact: Can make a person look older or constantly tired.
Generalized Facial Lipoatrophy
Description: Even fat loss across cheeks, temples, jawline, and around the eyes.
Appearance: Overall thinning of the face, loss of fullness.
Impact: Most dramatic; changes are obvious from all angles.
Asymmetrical Lipoatrophy
Description: One side of the face loses more fat than the other.
Appearance: Uneven cheeks or temples.
Impact: May draw attention and cause distress if one side of the face looks different.
Each type can be mild, moderate, or severe, depending on how much fat is lost. Mild cases may only be noticed by the person themselves, while severe cases are clear to anyone looking.
Causes of HIV-Associated Facial Lipoatrophy
Below are twenty factors that can lead to or worsen facial fat loss in people with HIV. While not everyone with these factors will develop lipoatrophy, each one plays a role in fat cell health.
Stavudine (d4T) Use
Many patients treated with stavudine experience mitochondrial damage. This drug was once common but is now used less because of its link to lipoatrophy.Zidovudine (AZT) Treatment
Like stavudine, zidovudine can harm mitochondria. Prolonged use increases risk of fat cell loss in the face.Didanosine (ddI) Exposure
Didanosine contributes to mitochondrial dysfunction, which can damage fat cells in various body areas, including the face.Protease Inhibitor Regimens
Certain protease inhibitors may change how the body handles fats, indirectly affecting facial fat stores over time.Chronic HIV Infection
Untreated HIV itself can cause chronic inflammation. This inflammation speeds up fat cell breakdown.High Levels of Cytokines
Cytokines like TNF-alpha and IL-6, released during immune activation, trigger fat cell death and hinder fat storage.Genetic Predisposition
Some people carry genes that make their fat cells more sensitive to damage from HIV or ART drugs.Oxidative Stress
An imbalance between free radicals and antioxidants can harm cells, including adipocytes (fat cells).Advanced Age
Older adults naturally lose fat under the skin. HIV-related changes can speed up this process.Poor Nutrition
Lack of essential nutrients such as vitamins C and E reduces antioxidant defenses, making fat cells vulnerable.Hormonal Imbalances
Changes in hormones like cortisol and insulin can shift fat distribution away from the face.Smoking
Tobacco smoke increases oxidative stress and inflammation, harming fat cell health.Alcohol Use
Heavy drinking can disrupt metabolism and increase fat breakdown, including in the face.Co-infection with Hepatitis C
Hepatitis C can worsen inflammation and liver function, affecting how the body manages fats.High Blood Sugar (Hyperglycemia)
Poorly controlled blood sugar levels damage small blood vessels and impact fat cell nourishment.Insulin Resistance
This common metabolic change in HIV patients can alter fat storage patterns, contributing to face thinning.Adipose Tissue Fibrosis
Scarring within fat tissue can reduce its ability to grow or store fat, leading to lipoatrophy.Mitochondrial DNA Mutations
Damage to mitochondrial DNA from certain drugs or the virus itself impairs fat cell energy production.Drug–Drug Interactions
Combining multiple HIV drugs can increase toxicity risks that harm fat cells more than single agents alone.Long Duration of ART
The longer a person takes certain ART drugs, the higher their cumulative risk of developing facial lipoatrophy.
Each cause alone may not be enough to trigger lipoatrophy, but when several factors combine, the chance of noticeable fat loss rises.
Symptoms of Facial Lipoatrophy
Facial lipoatrophy has both visible and personal effects. Here are fifteen common signs:
Sunken Cheeks
Cheekbones look sharp and hollow, with less soft padding.Hollow Temples
The area beside the eyes and above the cheekbones appears sunken.Prominent Jawline
Less cheek fat makes the jawbone stand out more.Deep Nasolabial Folds
Lines from the nose to the corners of the mouth become more pronounced.Visible Zygomatic Arch
The bone at the upper cheek area shows through thinner skin.Asymmetry of the Face
One side of the face may have more fat loss than the other.Sagging Skin
Without fat to hold it up, skin may sag or form loose folds.Loss of Facial Fullness
Overall face shape appears less plump and more gaunt.Noticeable Orbital Rim
The bone around the eye sockets becomes more obvious.Difficulty Fitting Glasses
Cheek hollows or temple grooves can make glasses sit unevenly.Self-Esteem Issues
Changes in appearance often lead to low confidence or social anxiety.Persistent Fatigue
While not directly caused by lipoatrophy, the stress and inflammation linked to it can worsen tiredness.Jaw or TMJ Discomfort
Altered support around the cheeks can change bite alignment, sometimes causing jaw pain.Fine Lines and Wrinkles
Loss of underlying fat makes fine lines more visible, especially around the eyes and mouth.Dry or Thin Skin
Reduced oil and fat under the skin can make it feel dryer and thinner.
People may notice some signs before others. Early detection helps patients talk to their doctor about possible management or changes in therapy.
Diagnostic Tests for HIV-Associated Facial Lipoatrophy
Doctors use a mix of simple exams and advanced tools to assess facial fat loss. Here are twenty diagnostic approaches, grouped by type:
A. Physical Exam
Visual Inspection
The doctor looks at the face from different angles under good lighting to spot hollows or asymmetry.Skinfold Thickness
Using skinfold calipers, the examiner measures how thick the skin and underlying fat are at key facial points.Anthropometric Measurements
Clinicians take distances between facial landmarks (e.g., cheekbone to jawline) to track changes over time.Manual Palpation
Feeling the face with hands helps estimate the softness and volume of subcutaneous fat.
B. Manual Tests
Cheek Pinch Test
Gently pinching the cheek helps gauge how much fat the skin holds. Less give suggests fat loss.Temporal Pinch Test
Pinching the temple area measures fat pad thickness near the hairline.Lipodystrophy Grading Scale
Using a standardized face chart, the clinician grades lipoatrophy severity on a scale from 0 (none) to 4 (severe).Mirror Self-Assessment
Patients compare their face to reference images in a mirror and note changes, providing personal insight.
C. Lab and Pathological Tests
CD4 Cell Count
Measures immune health. Lower counts can correlate with higher inflammation that harms fat tissue.HIV Viral Load
High levels of virus in the blood can drive chronic inflammation linked to fat loss.Lipid Profile
Checks cholesterol and triglyceride levels. Dyslipidemia may signal metabolic issues affecting fat distribution.Hormone Panel
Tests cortisol, insulin, and sex hormones to see if imbalances contribute to fat loss or redistribution.Adipokine Levels (Leptin/Adiponectin)
Measures fat-cell hormones. Low leptin and high adiponectin patterns often appear in lipoatrophy.Adipose Tissue Biopsy
In rare cases, a small fat sample is taken under local anesthesia to examine fat cell health under a microscope.
D. Electrodiagnostic Tests
Bioelectrical Impedance Analysis (BIA)
A sensor passes a tiny electrical current through the face to estimate water and fat content.Facial Electromyography (EMG)
Measures muscle activity to rule out nerve or muscle causes of facial changes.Nerve Conduction Studies
Tests nerve function around the face to ensure that fat loss is not due to neural damage.
E. Imaging Tests
Ultrasound of Subcutaneous Fat
A handheld probe measures the thickness of fat under the skin in targeted facial regions.Magnetic Resonance Imaging (MRI)
Provides high-resolution images of fat layers without radiation. Ideal for detailed mapping of fat loss.Computed Tomography (CT) Scan
Offers clear cross-sectional images of facial fat compartments. Used when MRI is not available.
By combining these tests, healthcare providers get a clear picture of how much fat is lost, where it is lost, and how quickly changes are happening. This helps them plan the best approach to prevent further loss and, if desired, restore lost volume.
Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.
The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members
Last Updated: August 06, 2025.
