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.