PLASMA STRONG FROM THROMBOCYTE (TZP)
Platelet rich plasma (PRP) was developed in the early 1970s as a byproduct of multicomposite blood products. Although it has been known that it has been used in orthopedic, 1 periodontic, 2 maxillofacial, 3 plastic, 4 thoracic, 5 vascular surgeries6-7 and ophthalmology8 since those years, it has recently attracted attention in its use in new indications in dermatology practice.
Plasma rich in autologous platelets; It refers to the plasma obtained from the person’s own blood using a centrifuge, with a high platelet concentration, which is strong from growth factors. Platelet density and activity in PRP is 4 times higher than in whole blood9. Platelets; In addition to its role in hemostasis, it also has a valuable role in tissue repair by secreting growth factors from α-granules in tissue damage10. alpha granules; platelet-derived growth factor (platelet-derived growth factor: PDGF), transforming growth factor α and β (transforming growth factor: TGF-α and TGF-β), epidermal growth factor (epidermal growth factor: EGF) and vascular endothelial growth factor ( Various growth factors such as vascular endothelial growth factor: VEGF) also contain cytokines and chemokines 11-14. Other secretory molecules known as growth factors, cytokines, chemokines and integrin are high in young platelets, and they continue to be secreted to a lesser extent during the 7-10 day life span of the platelets. . PDGF; It increases the number of fibroblasts in the damaged area by stimulating the growth of endothelial cells, and ensures the differentiation of neutrophils and monocytes. Thus, capillary vessel formation, increasing collagen production and granulation formation are supported. TGF-β plays a vital role in the restructuring of the skin: For example, in addition to stimulating collagen synthesis during the wound healing process, it also participates in the inflammatory response together with PDGF and stimulates the synthesis of the extracellular matrix12. EGF takes part in chemotaxis and stimulates the proliferation of keratinocytes and fibroblasts. Proliferating fibroblasts increase collagen production. VEGF stimulates the proliferation of endothelial cells, thereby increasing new vessel formation, increasing existing capillary permeability and contributing to the microenvironment necessary for cell growth and angiogenesis. Insulin-like growth factor (IGF) has a chemotactic role for vascular endothelial cells, including IGF-1 and IGF-2. Thus, it stimulates the migration of vascular endothelial cells to the damaged area, supports angiogenesis, and increases the rate of endothelial and epidermis regeneration with PDGF 12-16.
Dermatological uses of PRP
The idea of using platelet-strength plasma in the treatment stemmed from the fact that it contains a large amount of growth factor. Growth factors are clinically used in the treatment of chronic wounds, soft tissue damage, bone disorders, wrinkle removal and acute traumas. They are used in dermatological applications in various indications13-20. The results in these areas of use, presented in Table 1, are based on clinical observations and controlled studies are needed.
In a study by Eppley et al.13, it was suggested that autologous platelet factors could be used to accelerate epithelialization of granulation tissue in the treatment of chronic, non-healing cutaneous ulcers. It has been reported that this study is the first clinical application using autologous blood-derived activating factors that accelerate the healing of chronic skin ulcers. In another study, PRP was used in ulcers on the skin, and it was shown to be effective in accelerating the formation of granulation tissue and epithelialization in the tissue12.
Platelet-rich plasma is highly effective in facial and neck wrinkles, skin sagging and pigmentation problems that occur with the reduction of the underlying tissues of the skin over time. skin aging; It is a natural result of the interaction of environmental factors such as smoking, sun exposure (photoaging) and exposure to various chemicals, as well as the decrease in the protective functions of the skin as a result of chronological aging. UVB, which is the most valuable cause of photoaging, has been shown to increase collagenase production from dermal fibroblasts and stimulate collagenase gene expression21,22. In skin always exposed to UVB, collagen degeneration, disruption of dermal extracellular matrix integrity and changes in elastic tissue cause a decrease in skin resistance, leading to wrinkles. Application of topical growth factors; By increasing the synthesis of new collagen, it provides rejuvenation of the photo-aged facial skin and beautifies the clinical appearance17. Na JI et al.14 reported that after the application of PRP to patients after the fractional carbon dioxide laser applications used in wrinkle reduction and scar treatment, there was an acceleration in wound beautification, a decrease in discontinuous undesirable effects such as erythema, and an increase in skin firmness. PRP provides adequate vascularization without causing multi-vessel formation. Thus, the period of erythema that may develop after the fractional resurfacing CO2 laser is shortened14.
PRP application is successfully applied in the upper face area, forehead, eye wrinkles, zygomatic region sagging. Effective results are obtained as a result of PRP application in the wrinkles of the nose edge, sagging of the chin corners, sagging under the chin, wrinkles and sagging of the neck and décolleté in the middle and lower face area23.
Lee et al.15 observed that as a result of the addition of PRP injection to ablative carbon dioxide fractional laser application in the treatment of acne scar, the beautification was accelerated, although it was not statistically significant. In this study, after fractional laser application, 0.3 ml of PRP was applied intradermally to 20 points on one side of the face, with a center of 1.5-2 cm, and the results after 4 months were compared with the other half of the face that was applied saline. After 1 month, the process was repeated15.
On the other hand, Jeong et al.24 reported that they obtained satisfactory results with the application of intralesional PRP in an event with treatment-resistant lipodermatosclerosis.
TGF-β in PRP; It stimulates basement membrane protein secretion such as laminin, collagen IV and tenascin. It has been reported that pigmentation does not develop after fractional CO2 laser applied for lesions such as incontinence pigment, thanks to the rapid repair of the basement membrane. On the other hand, TGF-β is known to reduce melanogenesis25. Thus, it can be applied to pigmentation disorders caused by pregnancy, old age, sun damage, scars and striae on the skin.
With the PRP application, successful results are obtained in individuals with complaints of hair loss, broken hair, lifelessness and dull appearance on the scalp. Besides stopping hair loss, it activates hair growth by stimulating hair follicles. When the growth of thin hair is activated, they gain a thicker, healthier appearance. PRP application does not make the hair that has been completely shed over time to grow again, it is ensured that the existing hair is healthier, the shedding stops, and the hair becomes healthier. Takikawa M et al.26 also reported positive results in hair growth with PRP applications.
PRP preparation and application
Although there are various PRP preparation methods, few of them have been approved by the FDA (Ex: Smart PReP and platelet concentration collection system: PCCS). Platelet concentrations in plasma obtained with different systems increase 2-8 times, so the growth factors they contain are different27,28. Practitioners should prefer FDA-approved systems that can obtain more growth factors. To prepare the PRP, venous blood (anticoagulant/blood ratio: 1/10) is taken from the patient into anticoagulant tubes containing acid citrate dextrose (ACD), and shaken for 10 seconds to mix with each other. When centrifuged at low time (3000rpm, 3 minutes), three portions are distinguished in the tube. In the lower part there is erythrocytes, in the middle part of the platelet-leukocyte mixture called buffy coat, and at the top there is plasma. Concentrated PRP can be used by carefully pulling the buffy coat, or concentrated PRP is obtained by centrifuging the buffycoat and the upper platelet-poor plasma for 3 minutes at 4000 rpm15. The plasma obtained is only 10% of the blood taken. It is activated by adding platelet agonists such as thrombin, calcium gluconate or calcium chloride. Thus, platelets degranulate and growth factors are given to the environment. The release of these factors begins 10 minutes after blood clotting, and 95% of it is secreted within the first hour. The in vivo life of platelets is about 9-10 days, they can be stored at room temperature for 5 days with certain rules, but the growth factor release is essentially very low. During centrifugation, it is very important to use low G power to preserve the membrane stabilization of the platelets and to prevent platelet degranulation before the process15, 29,30.
Platelet-rich plasma can be administered topically or by injection. Injections are usually made intradermally or subdermally. Filling injection or injection techniques applied in mesotherapy can be used. Although there are not necessarily protocols about the application technique, for the scalp; point technique, nappa and point technique can be used together for skin rejuvenation, and tunnel technique can be used for filling. In the treatment of acne scars, a subcision can be made and PRP can be given to that area. Significant clinical improvement is observed in 1-2 weeks after PRP applications. For maximum effect, 2-3 weeks of moderate to 3-4 applications are required18,31.
Patients with thrombocytopenic, hypofibrinogenemia, liver disease, malignancy; The use of PRP should be avoided in acute and chronic infections, pregnant and lactating women, those with autoimmune diseases, and individuals with known sensitivity to blood and blood products32.
PRP side effects
The risk of side effects in PRP application is very low since the patient’s own platelets are used. Since the application is made by injection; Depending on the technique of injecting the injector into the skin, some local side effects may occur. The ecchymoses that may occur at the injection site are small in diameter and smooth out within a few days without the need for treatment. The redness that occurs during the application also disappears ex officio in 30-40 minutes without the need for treatment. After the application, the feeling of tension on the skin disappears within 1-2 hours. Since the patient’s own blood is used in the PRP application, it is not a matter of random allergic reaction.
As a result, PRP is a practical method and attracts attention as an alternative treatment method because it does not have significant side effects, does not form widespread scar tissue, does not cause malignant transformations, is easily available and can be obtained cheaply. However, there is a need to support these findings with large-scale clinical studies and experimental studies confirming their effects on fibroblasts.
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2. Hanna R, Trejo PM, Weltman RL. Treatment of intrabony defects with bovine-derived xenograft alone and in combination with platelet-rich plasma: a randomized clinical trial. J Periodontol 2004;75:1668-77.
3. 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;85:638-46.
4. Powell DM, Chang E, Farrior EH. Recovery from deep-plane rhytidectomy following unilateral wound treatment with autologous platelet gel: a pilot study. Arch Facial Plast Surg 2001;3:245-50.
5. Englert SJ, Estep TH, Ellis-Stoll CC. Autologous platelet gel applications during cardiovascular surgery: effect on wound healing. J Extra Corpor Technol 2005;37:148-52.
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8. Korobelnik JF, Hannouche D, Belayachi N, Branger M, Guez JE, Hoang-Xuan T. Autologous platelet concentrate as an adjunct in macular hole healing: a pilot study. Ophthalmology 1996;103:590-4.
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11. Weibrich G, Hansen T, Kleis W, et al. Effect of platelet concentration in platelet-rich plasma on peri-implant bone regeneration. Bone 2004;34:665-671
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14. Na JI, Choi JW, Choi HR, Jeong JB, Park KC, Youn SW, Huh,CH. Rapid healing and reduced erythema after ablative fractional carbon dioxide laser resurfacing combined with the application of autologous platelet-rich plasma. Dermatol Surg 2011;37:463–468.
15. Lee JW, Kim BJ, Kim MN, Mun S K. The Efficacy of autologous platelet rich plasma combined with ablative carbon dioxide fractional resurfacing for acne scars: A simultaneous split-face trial. Dermatol Surg 2011;37:931–938.
16. Crovetti G, Martinelli G, Issi M, Barone M, Guizzardi M, Campanati B, Carabelli A. Platelet gel for healing cutaneous chronic wounds. Tranfusion and Apheresis Sci 2004;30:145-151.
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19.Lemperle G, Holmes RE, Cohen SR et al. A classification of facial wrinkles.Plast Reconstr Surg 2001;108:1735-1750.
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21. Bernstein EF, Chen YQ, Kopp JB, Fisher L, Brown DB, Hahn PJ, et al. Long-term sun exposure alters the collagen of the papillary dermis. Comparison of sun-protected and photoaged skin by northern analysis, immunohistochemical staining, and confocal laser scanning microscopy. J Am Acad Dermatol 1996;34:209-218.
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23. Kim DH, Je YJ, Kim CD, Lee YH, et al. Can platelet- rich plasma be used for skin rejuvenation?EEvaluation of effects of platelet- rich plasma on human dermal fibroblast. Ann Dermatol 2011;23:424-431.
24. Jeong KH, Shin MK, Kim N. Refractory lipodermatosclerosis treated with intralesional platelet-rich plasma. J Am Acad Dermatol. 2011.06.040
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27. Zimmermann R, Jakubietz R, Strasser E, et al. Different preparation methods to obtain platelet component as a source of growth factors for local application .Transfusion 2001;41:1217-1224.
28. Marx RE. Platelet rich plasma : Evidence to support its use. J Oral Maxillofac Surg2004;62:489-496.
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Table 1. Dermatological Uses of PRP
Chronic skin ulcer
Wrinkle removal, skin rejuvenation
Wound in ablative laser, chemical peeling, roller applications
to increase and accelerate the beautification of