An ACMS Perspective Article written by Dr. Nicole Vélez of Pittsburgh Skin – August 2019

Platelet-Rich Plasma (PRP) has been used to promote soft tissue healing in several surgical specialties for decades. Over the past few years, PRP has also shown exciting promise in dermatology, particularly in the treatment of hair loss, acne scarring, and skin aging. Small studies also suggest PRP may provide benefit in chronic wounds and vitiligo¹   

 

What is PRP?

Platelet-rich plasma (PRP) is a fraction of plasma that contains 3 to 7-fold the mean platelet concentration of whole blood.  Platelets are of particular interest because they have α-granules, which when activated secrete numerous growth factors. These growth factors, including transforming growth factor-β , vascular endolthelial growth factor, epidermal growth factor, fibroblast growth factor, and insulin-like growth factor-1 (IGF-1), along with other proteins and chemokines interact with local tissue to promote cell differentiation, proliferation, and regeneration².

 

How is PRP Performed?

PRP is performed in an office setting. Blood is first drawn from a patient, usually 10-60 ml from the antecubital fossa.  Anticoagulants, such as sodium citrate, in the collecting vial prevent ex vivo coagulation. The blood is then placed in a centrifuge to separate cell types based on specific gravity. The platelet-rich plasma rises to the top while the platelet-poor plasma (red and white blood cells) remains on the bottom and is discarded. The PRP is extracted and combined with an activator (ie: calcium gluconate) which promotes growth factor excretion. Syringes of the activated PRP are then ready to use for injection or topical application to the scalp or face. A variety of PRP systems exist and while the general technique is the same, the amount of blood drawn and the concentration of PRP obtained varies.  This variation between systems can make comparison between studies challenging^2,3.

 

PRP for Hair Loss

Hair loss affects over 50% of the population. It has a significant impact on quality of life and has been associated with depression, introversion, and lower self-esteem⁵. Through secretion of growth factors, PRP is thought to promote perifollicular angiogenesis and the proliferation of dermal papillary cells.  Androgenetic alopecia, a non-scarring form of hair loss, is encountered most frequently and occurs in both men and women. In androgenetic alopecia, dihydrotestosterone (DHT) blocks IGF-1.  By secreting IFG-1, PRP may counteract this blockade. Scalp biopsies after treatment with PRP show increased number of hair follicles and improved follicle vascularity³. For treatment of androgenetic alopecia, PRP is usually injected in a series of three treatments, 4-6 weeks apart, followed by a booster treatment every 6-12 months.  Studies to date have been small but in general show improvement in hair count. One single center, blinded, randomized clinical trial showed 30% increase in hair count and hair density after 4 treatments at month 6 ⁶.

 

PRP for Acne Scarring

Acne vulgaris affects 90% of adolescents. Almost all patients develop some scarring while 30% report significant scarring. Treatment of scarring is challenging. Options include retinoids, chemical peels, microneedling and lasers.  Recently, PRP is being used as an adjunctive therapy to microneedling or fractional ablative laser for acne scars. Both microneedling and laser work by inducing microtrauma that is meant to trigger new collagen deposition and tissue remodeling. The microtrauma also creates small channels in the skin that can facilitate drug delivery.  By applying topical PRP to the skin after microneedling or laser, the growth factors may penetrate deeper into the skin. While there are no large randomized trials, most small studies show that the addition of PRP to either modality improves acne scarring, patient satisfaction, and postprocedural symptoms² .

 

Other Potential Uses

Chronic wounds are unfortunately common and associated with high morbidity and cost⁶. In a multicenter observational case series of 200 patients with refractory chronic wounds, topical PRP gel was applied once or twice a week. After a mean of 2.8 treatments, 86% of wounds saw a reduction in wound size by 47%⁷. In addition to wound healing, PRP application has been associated with pain reduction in chronic wounds.

Vitiligo, an autoimmune process which results in depigmentation, may also benefit from PRP. In vitiligo patients, PRP has been used in combination with phototherapy or CO2 ablative laser. Small studies show that the addition of PRP to either treatment results in better results than phototherapy or CO2 laser alone⁷.

Larger randomized trials are needed to fully evaluate PRP and it’s role in dermatology. More importantly, a standardized technique for acquiring and isolating PRP should be defined. Nevertheless, initial reports of PRP in dermatology are intriguing. Especially for our patients who may want to avoid systemic medications with potential adverse effects, PRP may provide an interesting alternative.  For several of these conditions which are challenging to treat, it is exciting to have the possibility of another treatment option in our armamentarium.

Dr. Nicole F. Vélez is a dermatologist and Mohs surgeon with Pittsburgh Skin: Dermatology & Mohs Surgery in Cranberry, PA. She can be reached at nfvelez@gmail.com.

 

References:

1. Hesseler MJ, Shyam N. Platelet-rich plasma and its utility in medical dermatology – A systematic review. J Am Acad Dermatolo 2019; [Epub ahead of print]
2. Hesseler MJ, Shyam N. Platelet-rich plasma and its utility in the treatment of acne scars: A systematic review. J Am Acad Dermatol 2019;80:1730-45.
3. Avram MR, Finney R. Platelet-rich plasma therapy for male and female pattern hair loss. Dermatol Surg 2019;45:80-82.
4. Kalyam K, Kavoussi SC, Ehrlich M, et al. Irreversible Blindness Following Periocular Autologous Platelet-Rich Plasma Skin Rejuvenation Treatment. Ophthalmic Plast Reconstr Surg. 2017 May/Jun;33(3S Suppl 1):S12-S16.
5. Hesseler MJ, Shyam N. Platelet-rich plasma and its utility in alopecia: A systematic review. Dermatol Surg 2019;00:1-16.
6. Hausauer AK, Jones DH. Evaluating the efficacy of different platelet-rich plasma regimens for management of androgenetic alopecia: a single-center, blinded, randomized clinical trial. Dermatol Surg 2018;44:1191-1200.
7. 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.