An Innovative Addition to the Clinical Toolbox
Michael Rahman, BSc, ND
The human body has a remarkable capacity to heal itself. Regeneration of new tissue is accomplished by stem cells and is fostered by growth factors and hormones. Platelet-rich plasma (PRP) is an emerging treatment in a new health sector known as orthobiologics, which refer to growth factors and proteins that are naturally found in the human body.
The body signals platelets and other components in our blood supply to migrate to the site of injury. Platelets are the injury’s first responders, and under normal conditions these platelets release various factors that initiate and subsequently stimulate bone and cartilage regeneration and repair, promote new blood vessel development to accelerate tissue regeneration, and stop the bleeding. Platelets release many other bioactive proteins responsible for attracting macrophages, mesenchymal stem cells, and osteoblasts.1
Inside the platelet are 2 types of granules, namely, alpha granules and dense bodies. Alpha granules contain the clotting and growth factors that are released in the healing process. Normally at the resting state, platelets require a trigger to activate and become a participant in wound healing and hemostasis.
Growth factors and other cytokines in platelets include the following: platelet-derived growth factor, transforming growth factor, fibroblast growth factor, insulinlike growth factor 1, insulinlike growth factor 2, vascular endothelial growth factor, epidermal growth factor, interleukin 8, keratinocyte growth factor, and connective tissue growth factor.
The natural healing cascade is not always inherent on injury. Often, the body’s healing process does not work efficiently, and instead of forming healthy collagen fibers and remodeling tissue, significant scar tissue develops in its place. One of the main risk factors is a lack of blood flow to the area to circulate the healing powers of the platelets and growth factors. The development of scar tissue prohibits proper blood flow because new capillaries and other small blood vessels cannot penetrate through scar tissue to provide blood flow to the injured area. For this reason, the affected joint, tendon, ligament, muscle, dermis, or soft-tissue area fails to heal completely.2
Modern technology allows us to concentrate platelets and white blood cells from a patient’s blood (autologous therapy) and to induce the release of growth factors by injecting the solution directly into injured tissue, simulating the same healing response but in a more directed form. By enhancing the body’s natural healing capacity, the treatment may lead to more rapid, efficient, and thorough restoration of the tissue to a healthy state.
Advantages of Using PRP
Advantages of using PRP include the following: tissue regeneration and rejuvenation, induction of cell differentiation, extracellular matrix formation, recruitment of other cells to the site of injury, and an increase in collagen production, which can increase skin thickness and overall skin health. In addition, PRP is nonallergenic, is an autologous physiological product, eliminates donor transmissible infections, and is a biological glue for tissue adhesion, especially in skin flaps, bone grafts, and trauma.3
Preparation of PRP
To prepare PRP, a small amount of blood is drawn from the patient’s arm. The blood is then placed in a centrifuge that spins at high speed and separates the platelets from the rest of the blood components. The typical baseline blood platelet count is approximately 200 000 per microliter; therapeutic PRP centrifuges concentrate the platelets by roughly 5-fold. However, broad variability exists in the production of PRP by various concentrating equipment and techniques. The platelets collected in PRP are activated by the addition of thrombin and/or calcium glucarate, which induces the release of these factors from alpha granules. In my practice, the ratio of volume is one-tenth the volume of PRP harvested after spinning.
The entire process takes less than 15 minutes and increases the concentration of platelets and growth factors up to 600%, along with an inherent rise in human stem cell proliferation due to exposure to concentrated platelets up to 10 times above native levels. The concentrated PRP is then injected into and around the affected area, jump-starting and significantly strengthening the body’s natural healing signals. Injections of PRP heal the area over time, during 1 to 3 months. Because the patient’s blood is used, there is no risk of a transmissible infection and a low risk of allergic reaction.
Clinical Applications and Procedure
In humans, PRP has been investigated and used as a clinical tool for several types of medical treatments, including nerve injury, tendonitis, osteoarthritis, cardiac muscle injury, bone repair and regeneration, plastic surgery, and oral surgery. It has received attention in the popular media because of its use in treating sports injuries in professional athletes.
Aging of the skin, dermal components, and cells means that the skin texture and appearance deteriorate and have been damaged. Aging affects the hands and soft tissue of the face, neck, and décolleté. This is characterized by sagging jowls, thinning of the skin, puffiness, age spots, and wrinkling.
In dermatology and cosmetic medicine, PRP has been used to treat acne, scarring, and alopecia (especially in women). It is also effective for skin rejuvenation and tightening around the eyes (for thin crepe-like skin and fine lines) and in the following areas: cheeks and midface, thinning skin on the neck, jawline and submalar regions, back of hands, décolleté, and others (eg, knees, elbows, and upper arms, as well as for postpregnancy skin laxity).
Platelet-rich plasma is injected by multiple tiny punctures under the dermis, with or without topical local anesthesia. The process is painless if sufficient topical anesthesia is applied. When PRP is injected into the damaged area, it stimulates the tissue, causing mild inflammation that triggers the healing cascade. As a result, new collagen begins to develop. As this collagen matures, it begins to shrink and tightens and strengthens the skin, as well as the tendons and ligaments of the damaged area when it is injected at that level. Improvement in skin texture and tone is noticeable within 3 weeks. Full collagen regeneration requires 3 months. Topical skin care and light therapies can enhance these results. Advanced wrinkling cannot be reversed, and severe scarring may not respond to treatment. In my experience, surgical scars respond well cosmetically.
The PRP treatments can be used on all skin types and tones. Minimal swelling, bruising, and redness for the initial 12 to 24 hours are expected. A bruise at the needlestick site may be visible for 2 to 3 days. Swelling from the fluid is what the patient will notice first. During several weeks, the platelets stimulate growth factors, which assists in more collagen stimulation. Treatment results vary but last up to 18 months in most patients. Biannual touch-up treatments will maintain the results.
As an initial treatment strategy, up to 3 injections may be given within a 6-month time frame. These are usually performed 2 to 3 weeks apart.
Considerations Before PRP Treatment
Certain factors (eg, smoking and alcohol intake) diminish stem cell release. Avoiding these will increase the success of the PRP procedure. The platelets work by causing an inflammatory reaction. If this inflammatory reaction is diminished, the clinical outcome is significantly compromised. For this reason, the use of anti-inflammatory drugs is not recommended. This restriction should be in place for about 1 to 2 weeks. Proponents of PRP therapy argue that negative clinical results are associated with poor-quality PRP harvest or concentration by inadequate devices. The specification that gathering devices capture a percentage of a given thrombocyte count is a marketing bias because significant individual variability exists in the platelet concentration of human plasma. More is not necessarily better in this case. Variability in platelet concentrating techniques may alter platelet degranulation characteristics, which could affect clinical results.
Exclusion Criteria for PRP Treatment
Although PRP is a promising therapy for most patients, the practitioner must take into account some considerations during the initial assessment before suggesting this treatment. Contraindications include the following: sepsis, cancer, chemotherapy, platelet dysfunction syndrome, critical thrombocytopenia, hypofibrinogenemia, hemodynamic instability, anticoagulation therapy, acute and chronic infections, chronic pathological conditions of the liver, severe metabolic and systemic disorders, and skin disease (systemic lupus erythematosus, porphyria, and allergies), as well as heavy nicotine, drug, and alcohol consumption.
Adverse Effects of PRP Treatment
Adverse effects of PRP treatment may occur, some of which are significant. The most common adverse effects are infection, skin discoloration and bruising, pain in the injected area, allergic reaction (a rare occurrence), and blood clot (because PRP therapy uses a needle, a vein could be damaged).
A Final Word About PRP and Hair Growth
In my practice, the most promising use of PRP is to treat alopecia. The platelets secrete growth factors, including platelet-derived growth factor and vascular endothelial growth factor, both of which have positive effects on hair growth. Platelet-derived growth factor is one of numerous growth factors or proteins that regulate cell growth and division. In particular, it has a significant role in the formation of blood vessels (angiogenesis) and the growth of blood vessels from already existing blood vessel tissue. Vascular endothelial growth factor is a chemical signal produced by cells that stimulates the growth of new blood vessels. It is part of the system that restores the oxygen supply to tissues when blood circulation is inadequate.
Before injecting PRP to treat hair loss, a tiny scalp roller with spikes is used to stimulate the thinning areas. The rationale is that this sends a message to the hair follicles to start the healing process. Then, PRP is injected over the affected area to further stimulate stem cells in the follicle.
Technique Is Key
As with all therapies, adequate training and experience are paramount. The beauty of the PRP technique, especially in dermatology and as an adjunctive tool in practice, is that it can be used as part of a multifaceted or layered approach. Significant clinical outcomes can be obtained with concomitant use of light therapies, fillers, and mesother-apy, as well as patient-directed home skin care regimens.
Michael Rahman, BSc, ND is a naturopathic physician, practicing for 13 years, who owns clinics in Toronto, Ontario, Canada, and in Durham, North Carolina. After obtaining his bachelor of science degree at McMaster University (Hamilton, Ontario), he attended the Canadian College of Naturopathic Medicine (Toronto). Dr Rahman’s practice focuses on biological medicine and its treatment of chronic diseases, healthy age management, and the blending of naturopathic medicine with cosmetic approaches and technology. He instructs NDs across North America on naturopathic care, natural noninvasive cosmetic medicine, and advanced homotoxicological approaches to disease. Contact Dr Rahman at [email protected].
References
Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85(6):638-646.
Antoniades HN, Williams LT. Human platelet–derived growth factor: structure and functions. Federation Proc. 1983;42:2630-2634.
Pierce GF, Tarpley JE, Yanagihara D, Mustoe TA, Fox GM, Thomason A. Platelet-derived growth factor (BB homodimer), transforming growth factor-beta 1, and basic fibroblast growth factor in dermal wound healing: neovessel and matrix formation and cessation of repair. Am J Pathol. 1992;140(6):1375-1388.
