Advances in Skin & Wound Care:
Richard “Sal” Salcido, MD, is the Editor-in-Chief of Advances in Skin & Wound Care and the Course Director for the Annual Clinical Symposium on Advances in Skin & Wound Care. He is the William Erdman Professor, Department of Rehabilitation Medicine; Senior Fellow, Institute on Aging; and Associate, Institute of Medicine and Bioengineering, at the University of Pennsylvania Health System, Philadelphia.
There is a small but growing trend in various specialties in the application of autologous platelet-rich plasma (APRP) for the treatment of acute and chronic inflammatory processes, including tendinopathies, musculoskeletal pain, and even chronic wounds, all under the emerging concept of regenerative medicine.1
Platelet-rich plasma (PRP), as a hematologic modality, is applied either topically on a wound or as a local or intra-articular injection. It is most commonly used in orthopedics, podiatry, dentistry, plastic surgery, and, potentially, in general acute and chronic wound care.2,3 Human PRP is derived from the patient’s own whole blood, which is extracted from the patient through a venous blood draw and then mechanically centrifuged to extract a concentrate in the form of usable APRP. The APRP is then reinjected in local areas of the body—most commonly the knee, elbow, tendons, and joints. The plasma contains a growth factor agonist (enabler) and has both mitogenic and chemotactic properties. It also contains a high level of platelets and a full complement of clotting and growth factors. There are few clinical trials and evidence-based medicine to support the routine use of PRP; moreover, the reimbursement for this procedure is unclear.
The use of APRP for chronic wounds and the various clinical applications cited in the literature follow a well-recognized story and trajectory for the life cycle of novel and off-label therapies, such as electrotherapy and negative-pressure wound therapy, and their path to recognition. I propose the path to recognition for these types of modalities follow this model: (1) usually start out as a “fad”, (2) proceed to a fledgling trend, (3) become a measurable trend, and (4) finally, create a continuum leading to peer review and evidence-based practice for which a practitioner is appropriately reimbursed and the patient gets better. In the case of APRP, it has certainly had its “fits and starts” and is seeing a small resurgence.
In 2008, Doughty4 attempted to build a theoretical model using a database of 200,000 patients. The model simulated the clinical, cost, and quality-adjusted life-year outcomes associated with PRP gel versus other modalities in treating nonhealing diabetic foot ulcers over a 5-year period. Their theoretical model concluded that the use of PRP gel had the potential to improve quality of life and lower the cost of care more than other treatment modalities for nonhealing diabetic foot ulcers. The caveat in this model was that it was a simulation model, in which they extrapolated their findings in a hypothetical way and lacked clinical significance because of the methods and study design.
Carter et al5 conducted a large meta-analysis looking at “10 years of studies,” in which the screening for protocol eligibility revealed a total of 24 usable articles. The meta-analysis of chronic wound studies revealed that APRP therapy was “significantly favored” for complete healing. The meta-analysis of acute wounds with primary closure studies demonstrated that the presence of infection was reduced in PRP-treated wounds. Their systematic review and meta-analysis of APRP in cutaneous wounds showed that complete and partial wound healing was improved compared with the standard wound care control group. One limitation of this systematic review was that although many citations evaluated the impact of PRP treatment on wound healing, there are many methods and definitions for determining and measuring wound healing.
As the literature pool grows, clinicians will be able to evaluate more evidence on the effectiveness of APRP in chronic wounds.
Richard “Sal” Salcido, MD
1. Langer HF, Gawaz M. Platelets in regenerative medicine. Basic Res Cardiol 2008; 103: 299–307.
2. de Leon JM, Driver VR, Fylling CP, et al. The clinical relevance of treating chronic wounds with an enhanced near-physiological concentration of platelet-rich plasma gel. Adv Skin Wound Care 2011; 24: 357–68.
3. Driver VR, Hanft J, Fylling CP, Beriou JMAutologel Diabetic Foot Ulcer Study Group. A prospective, randomized, controlled trial of autologous platelet-rich plasma gel for the treatment of diabetic foot ulcers. Ostomy Wound Manage 2006; 52 (6): 68–70, 72, 74.
4. Dougherty EJ. An evidence-based model comparing the cost-effectiveness of platelet-rich plasma gel to alternative therapies for patients with nonhealing diabetic foot ulcers. Adv Skin Wound Care 2008; 21: 568–75.
5. Carter MJ, Fylling CP, Parnell LK. Use of platelet rich plasma gel on wound healing: a systematic review and meta-analysis. Eplasty 2011; 11: e38.