From lipodystrophy to subcutaneous insulin depots: Overlooked mechanisms of glycemic variability in patients with diabetes

Table 1 Ultrasound grading of lipohypertrophy lesions and suggested clinical considerations

Grade	Ultrasound imaging characteristics	Suggested clinical considerations
Grade 0	Normal (no nodules or diffuse areas)	Continue routine site rotation education and periodic site checks
Grade 1	Diffuse hyperechogenic areas without clear nodules	Avoid repeated injections into the same area; reinforce rotation and needle single-use; consider ultrasound mapping if glycemia remains unstable
Grade 2	Nodules 1-5.9 mm (width at widest point)	Avoid injecting into lesion; monitor closely when switching to unaffected tissue because absorption may increase; reinforce education and rotation
Grade 3	Nodules 6-9.9 mm	As Grade 2, with heightened vigilance and closer monitoring during site change in patients with prior hypoglycemia/Large dose requirements
Grade 4	Nodules ≥ 10 mm	Strictly avoid injections into lesion; lesions may persist longer and require sustained site avoidance and monitoring; consider follow-up ultrasound in selected patients

This table was conceptualized and synthesized by the authors based on references[2,8,11,12,14,20,21].