PRP Versus PRF Versus Conventional Treatment in Chronic Non-healing Skin Ulcers

To compare the therapeutic efficacy of PRP and PRF: two relatively newer modalities in the management of chronic non-healing ulcers versus conventional treatment.

An ulcer is a breach in the continuity of skin, epithelium or mucous membrane caused by sloughing out of inflamed necrotic tissue. Chronic ulcers are formed because of the failure in the orderly process that produces anatomic and functional integrity. Ulcers are considered chronic if they show no tendency to heal after six weeks of appropriate treatment or those that have not fully healed after 12 months.

Despite greater understanding of the biology of wound healing over the past 20 years, some chronic wounds, such as venous leg ulcers, pressure ulcers, and diabetic foot ulcers, are recalcitrant to healing.

In addition to local wound-related factors (eg, ischemia, infection) and patient related factors (eg, diabetes, old age, obesity, malnutrition) that can impair healing, reduction in tissue growth factors, an imbalance between proteolytic enzymes and their inhibitors, and the presence of senescent cells seem to be particularly important in chronic wounds.

Regardless of the underlying etiology, non-healing ulcers tend to have chronic pain, discharge, sleep impairment, and subsequent adverse repercussions in quality of life and productivity, and impose a huge economic burden on the medical system.

In the United States, chronic ulcers including decubitus, vascular, inflammatory, and rheumatologic subtypes affect 6 million people, with increasing numbers anticipated in a growing elderly and diabetic populations.

Venous, arterial, and neuropathic ulcers account for up to 90 percent of ulcers. In a survey study in which wound care professionals in Germany reported the etiologies of chronic leg ulcers in over 31,000 patients, venous insufficiency, arterial insufficiency, and mixed venous and arterial insufficiency accounted for 48, 15, and 18 percent of chronic ulcers, respectively. There are multiple less common causes of ulcers, including physical injury, infection, vasculopathy, pyoderma gangrenosum, panniculitis, malignancy, medications.

The characteristics and difficulties in healing chronic ulcers lie in the lack of an adequate blood supply, long-term repeated inflammatory stimulation in the surrounding tissues, and the presence of a dead cavity. For chronic ulcers, the key is to determine the cause, determine the factors that affect the healing process, and create an environment suitable for healing to effectively treat the wound.

Current therapies include debridement, offloading, etc. However, the response to treatment is often poor, and the outcome is disappointing. These wounds place the limb at the risk of infection and amputation and also puts the patients at risk of mortality.

Chronic ulcers are known to have reduced levels of platelet-derived growth factor, basic fibroblast growth factor, epidermal growth factor, and transforming growth factorβ compared with acute wounds. It has been suggested that growth factors may become trapped by extracellular matrix molecules or may be degraded by proteases to an excessive degree, resulting in non-healing.

Many of the growth factors released from platelets play an important role in the wound-healing process, and topical application of concentrated activated platelets can stimulate wound healing in situations where standard wound care treatments are ineffective.

Platelet-rich concentrates, known as autologous platelet concentrates (APCs), have garnered significant attention in recent years and demonstrate remarkable potential in wound treatment.

Previous studies have shown that activated platelets undergo exocytosis of intracellular granules containing growth factors such as platelet-derived growth factor (PDGF), transforming growth factor-β (TGF-β), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), and insulin like growth factor (IGF). These growth factors contribute to wound healing by promoting regeneration and wound repair, thereby elucidating the efficacy of APCs therapy in skin regeneration, acne scar treatment, and enhanced wound healing.

APCs can be further classified into platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) based on distinct preparation processes, each with varied clinical applications. PRP, as the first-generation platelet concentrate, is plasma with a high platelet concentration obtained through specific centrifugation of fresh whole blood. PRP contains platelet concentrations four to five times higher than that of whole blood. It has demonstrated positive effects on bone regeneration and wound healing.

PRF, on the other hand, as the second-generation platelet concentrate, exhibits a slow release of growth factors, thereby prolonging their action.

APCs has a greater capacity to modulate the local microenvironment and expedite tissue regeneration. It has also been observed to alleviate pain, accelerate epithelization, and facilitate complete wound healing.

Currently, PRP and PRF, whose therapeutic value is equal to that of stem cells, are currently one of the most promising therapy agents in regenerative medicine. They are increasingly being used in different areas of medicine including aesthetic dermatology, orthopedics, sports medicine and surgery.

Because of the lack of sufficient literature, our study aimed to compare the efficacy of PRP versus PRF versus conventional treatment as a relatively newer modalities in the management of chronic non-healing skin ulcers.

Eligibility Criteria:
Inclusion Criteria:

* Patients presenting with cutaneous ulcers greater than six weeks of duration and a size ranging between 0.5 and 10 cm, having a normal platelet count and hemoglobin \>10 gm%.

Exclusion Criteria:

* Patients with known bleeding disorders, and/or on oral anticoagulant therapy, uncontrolled diabetes, proven malignancy.
* Patients who are pregnant or lactating.
* Patients with actively infected ulcers, clinically defined by purulent discharge, green discoloration or fever, or positive culture, ulcers with exposed bone with no underlying granulation tissue, HIV, HCV, HBV patients.
* Patients who are with unrealistic expectations and unwilling to give consent for treatment or photography.