Platelet-rich Plasma Improves Healing of Pressure Ulcers as Objectively Assessed by Digital Planimetry

Evangelos Volakakis, MD; Marios Papadakis, MD, PhD; Andreas Manios, MD; Christos V. Ioannou, MD, PhD; Odysseas Zoras, MD, PhD; Eelco de Bree, MD, PhD

Disclosures

Wounds. 2019;31(10):252-256. 

In This Article

Abstract and Introduction

Abstract

Introduction: The effectiveness of autologous platelet-rich plasma (PRP) in chronic wounds remains controversial.

Objective: The aim of this prospective study is to objectively assess the impact of PRP therapy on pressure ulcer (PU) healing utilizing digital planimetry.

Materials and Methods: Eligible patients included those with PUs with a surface area > 1 cm2 and > 3 months' duration. Each ulcer initially was debrided surgically. The patient then was advised to continue conventional treatment for 4 weeks, after which time repeat debridement was performed as needed. Subsequently, PRP was applied and the patient was observed for an additional 4 weeks. During the 8-week study period, the treatment's effectiveness was assessed weekly with digital planimetry. The Wilcoxon signed-rank test was used to compare continuous variables.

Results: Thirty-six patients (22 men, 14 women) with a median age of 62 years (range, 38–88 years), who had 64 PUs with an initial median surface area of 20 cm2 (range, 1 cm2–180 cm2), a median diameter of 6.3 cm (range, 1.3 cm–18.6 cm), and a median circumference of 16.8 cm (range, 4 cm–68 cm) were included. Reduction of median surface area (63% vs. 41%), median maximal diameter (33% vs. 20%), and median circumference (38% vs. 21%) were significantly (P < .001) greater after PRP treatment compared with after conventional treatment.

Conclusions: It appears treatment with PRP accelerates healing of PUs as objectively measured by digital planimetry. Compared with conventional treatment, a significantly higher reduction in surface area, diameter, and circumference of PUs was observed following application of PRP.

Introduction

A chronic wound is defined as a wound that failed to reach anatomic and functional integrity through an orderly and timely reparative process within a reasonable time frame (ie, 3 months).[1] Chronic wounds, such as diabetic foot ulcers, venous leg ulcers, and pressure ulcers (PUs), occur in about 2% of the population in developed countries.[2] They are intractable and increasing in prevalence, representing a serious impact on patient quality of life and health care costs.

Hydrocolloids, alginates, foams, sulfadiazine silver patches, honey gauzes, and other ointments and dressings have been described to promote chronic wound healing.[3] In a recent systematic review,[4] it was unclear whether these local interventions significantly increase the probability of ulcer healing. Other interventions include hyperbaric oxygen (HBO) and negative pressure wound therapy (NPWT) systems. There is evidence that HBO and NPWT can induce and accelerate wound healing by acting on 1 or more of the wound healing steps; however, limited availability, patients' intolerance, and high costs are among the disadvantages of these methods.[3]

The authors have developed an alternative approach based on direct exposure of autologous-concentrated plasma to the wound to enhance the wound environment. Due to its high content of platelets, this plasma is also known as platelet-rich plasma (PRP) and contains several growth factors (platelet-derived growth factor [PDGF]-AB, vascular endothelial growth factor-A, epidermal growth factor, transforming growth factor (TGF)-β1, insulin-like growth factor 1) in higher concentrations, compared with their levels in blood. These growth factors demonstrate various functions, such as inducing neovascularization, promoting fibroblast proliferation, stimulating keratinocytes, expressing regenerative epidermal phenotype, and enhancing phagocytosis and immunological response through local accumulation of polymorphonuclear leukocytes and macrophages.[5] No significant PRP treatment-specific adverse effects have been reported, most probably because it consists of autologous products.[6,7]

Despite this fact, the effectiveness of PRP in chronic wounds remains controversial, with several studies of high-evidence level reporting contradictory results. Carter et al[6] showed in their meta-analysis that PRP therapy can have a positive impact on wound healing and associated factors, such as pain and infection, in both chronic and acute wounds. Kontopodis et al[7] showed a significant benefit in the use of PRP in managing chronic foot ulcers in patients with diabetes with peripheral arterial disease. However, a Cochrane-based meta-analysis[8] concluded the impact of PRP on healing of chronic wounds other than diabetic foot ulcers is unclear. This meta-analysis of 10 randomized studies,[8] including a total of 442 patients with chronic wounds, did not show any improvement of healing when compared with standard care (risk ratio, 1.19; 95% confidence interval, 0.95–1.50). The authors found the overall quality of evidence for autologous PRP for treating chronic wounds is low due to the small number of randomized studies, which are, in addition, underpowered to detect treatment effects, if they exist, and generally at high or unclear risk of bias, including bias in outcome assessment and reporting.[8] Inhomogeneity in assessment of chronic wounds among health care professionals is well documented.[9] While computer-based diagnostics are established in other areas of medicine (eg, radiology, orthopedics, ophthalmology, and audiometry), accurate wound documentation is rarely conducted and often limited to size measurement with a ruler and rough photo documentation.[9] This highlights the need of a standard technique of accurate objective evaluation of the effectiveness of PRP in chronic wounds. Digital planimetry, which is based on serial measurements of ulcer dimensions and calculation of wound margin advancement towards the center of the lesion, could be a potential method.[10] The aim of this prospective study is to objectively assess the impact of PRP treatment on PU healing using digital planimetry.

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