practice
Effectiveness of autologous platelet-rich
plasma gel in the treatment of hard-to-
heal leg ulcers: a randomised control trial
Objective: Regenerative medicine products such as autologous
platelet-rich plasma (autologous PRP) gel may speed up the process
of healing. Clinical studies show promising results in the treatment of
diabetic foot ulcers (DFUs), however there is lack of scientific
evidence of autologous PRP effectiveness in treating leg ulcers of
other aetiology. This study evaluates the effectiveness of autologous
PRP gel in the treatment of hard-to-heal leg ulcers compared with
existing conventional treatment.
Method: A prospective, randomised controlled, open-labelled
clinical trial was carried out between 2014 and 2018. An eight-week
study protocol was chosen or until 100% wound re-epithelialisation
was observed. Wound size reduction, granulation tissue formation,
microbiological wound bed changes and safety were evaluated.
Results: A total of 69 patients (35 in the autologous PRP group and
34 in the control group) were included in the study; 25.71% of the
autologous PRP group and 17.64% of control group had ulcers
completely re-epithelialised (p>0.05). Wound size reduction in the
autologous PRP group was 52.35% and 33.36% in the control group
autologous platelet-rich plasma  ●  chronic wound  ● hard-to-heal ●  leg ulcer  ● PRP ●  wound
W
ound healing is a dynamic process
consisting of four stages: haemostasis,
inflammation, proliferation and
remodelling (maturation). The majority
of wounds heal in 2–4 weeks, passing
through all healing stages without complication.1
Wounds with an interrupted sequence of healing and
failure to restore anatomical and functional skin integrity
within three months are typically called chronic or hard-
to-heal ulcers.1 The most common chronic wounds/ulcer
localisation is in the lower limbs.2
Hard-to-heal leg ulcers have become a major public
health issue according to epidemiological data.2
Prevalence of leg ulcers among adults is estimated to be
3% worldwide, while in the population aged
*Domantas Rainys,1,2 MD, Plastic Surgeon; Adas Cepas,1,2 MD;
Karolina Dambrauskaite,2 MD; Irena Nedzelskiene,3 Mathematical Statistician;
Rytis Rimdeika,1,2 MD, PhD, Professor, Plastic Surgeon
*Corresponding author email: domantas.rainys@gmail.com
1  Hospital of Lithuanian University of Health Sciences Kauno Klinikos Plastic and
Reconstructive Surgery Department, Eivenių str. 2, LT 50009 Kaunas, Lithuania.  neoplasms and other conditions.11–13 Poor healing of
2  Lithuanian University of Health Sciences, Medical Faculty, A. Mickevičiaus str. 9,
LT 44307 Kaunas, Lithuania.  3  Lithuanian University of Health Sciences, Odontology
faculty, Department of Dental and Oral Diseases, Senior Statistician, Eivenių str. 2, LT
50009 Kaunas, Lithuania.  the tissues, necrotic tissue and other wound debris) and
658
(p=0.003). The autologous PRP group showed superiority over
conventional treatment in wound bed coverage with granulation
(p=0.001). However, more frequent wound contamination was
observed at the end of treatment in the autologous PRP group
(p=0.024). No severe adverse events were noted during the study.
Both treatment methods were considered equally safe.
Conclusion: Topical application of autologous PRP gel in leg ulcers
of various aetiology show beneficial results in wound size reduction
and induces the granulation tissue formation. However, it is
associated with more frequent microbiological wound contamination.
Declaration of interest: This clinical study is partially funded by
Lithuanian University of Health Sciences and RegenLab SA.
Lithuanian University of Health Sciences covered the fee for clinical
investigation approvals from the ethical committee and expenses
related to compression therapy bandage. Per agreement, RegenLab
SA provided the RegenKit-BCT kits for PRP gel preparation. The
involved research personnel have no personal economic interests in
the outcome of this investigation.
60–80  years, it is 5%.3–7 Moreover, frequency of
complications related to hard-to-heal leg ulcers such as
infection or amputation, which interrupts functionality
and general wellbeing of the patient, also increases.5
Due to the dramatically ageing population, it is expected
that the spread of leg ulcers will increase since poor
wound healing possibilities are directly related to age
and comorbidities, such as arterial hypertension,
diabetes and obesity.2,8 The costs related to the
treatment of hard-to-heal leg wounds are as much as 50
million US dollars in the US alone, while in the
European Union they are 1–2% of the annual health-
care budget.2,9,10
While causes of hard-to-heal leg ulcers are associated
with various aetiology, most are of vascular origin (60–
80%).11,12 The most frequent among those are venous
ulcers (60–76%), followed by arterial and mixed
(arterial-venous) ulcers.11,12 Neuropathic ulcers account
for about 5% of all leg ulcers and are the most common
in patients with diabetes.12 Other ulcers (~10%) occur
© 2019 MA Healthcare ltd
as a result of skin diseases including vasculitis, skin
leg ulcers could be associated with various regional
(wound infection, tissue hypoxia, repeated trauma of
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 practice

Additional strategies to improve tissue regeneration

Fig 1. CONSORT 2010 Flow Diagram
and wound healing are use of growth factors and
biological compounds obtained from autologous
Assessed for eligibility
platelet-rich plasma (PRP).18–21 The autologous PRP
(n=227)
mechanism is based on the physiological composition
Enrollment

of platelets. Platelets perform a major role in

Excluded (n=153) physiological wound healing processes, not only
• Not meeting inclusion
ensuring haemostasis and clot formation, but also
criteria/declined to
participate (n=146) regulating inflammation, angiogenesis, cell migration
• Other reasons (n=7) and proliferation.20,21 Platelets, from their dense
granules, lysosomes and alpha granules, release various
biologically active substances including growth factors
Randomised
(n=74)
and cytokines, which modulate tissue regeneration
processes.17 The main platelet-derived growth factors
modulating wound healing are:21–27
Allocation

●● Epidermal growth factor (EGF) stimulates fibroblasts

to secrete collagenases in order to degrade the ECM
PRP group (n=37) Control group (n=37) during the remodelling phase and encourages
• Received allocated • Received allocated keratinocyte and fibroblast proliferation
intervention (n=37) intervention (n=37)
●● Tumour growth factor α (TGFα) has a mitogenic and
chemotactic impact on keratinocytes and fibroblasts
●● Tumour growth factor β1 (TGFβ1) and tumour growth
Discontinued factor β2 (TGFβ2) promote angiogenesis, upregulate
Follow up

Discontinued intervention:
intervention collagen production, inhibit degradation and
• Infection (n=2)
• Infection (n=2) • Declined to continue
stimulate chemo-attraction of inflammatory cells
treatment (n=1) ●● Vascular endothelial growth factor (VEGF) stimulates
angiogenesis during tissue hypoxia
●● Fibroblast growth factor (FGF) promotes angiogenesis,
granulation and epithelialisation via endothelial cell,
Analysis

fibroblast and keratinocyte migration

Analysed (n=35) Analysed (n=34)
PRP—platelet-rich plasma
systemic (systemic diseases, diabetes, immuno-
suppressive diseases, insufficient nutrition) risk
factors.14 Because of the pathophysiological and
metabolic changes caused by these risk factors, the
normal wound healing process is interrupted.14,15
Moreover, high concentration of pro‑inflammatory
cytokines and high activity of matrix metalloproteinases
(MMPs) are registered in the wound bed which cause
degradation of growth factors and inhibit extracellular
matrix (ECM) formation and mitotic activity of
fibroblasts.15 Due to these processes, normal linear
wound healing is interrupted — the wound stalls in
inflammatory phase and becomes hard-to-heal.14,15
The most important aspect in the treatment of
hard‑to-heal leg ulcers is to determine the wound
aetiology and control the causes effectively.11 However,
modern dressings used for wound treatment do not
contain growth factors necessary for the wounds stalled
in the inflammatory phase.16,17 Despite adequate local
●● Platelet derived growth factor (PDGF) enhances
migration of macrophages and fibroblasts, and
promotes collagen and proteoglycan synthesis.
Treatment of hard-to-heal leg ulcers with autologous
PRP is not considered an aetiological treatment as it does
not eradicate the cause of the condition, but instead
deals with the consequences of the pathogenic
environment. Interest in the use of autologous PRP is
increasing worldwide due to poor outcomes of
conventional treatment methods and the increasing
frequency of hard-to-heal leg wounds in the ageing
population.3–5 The goal of this research is to evaluate the
efficiency of autologous PRP treatment in comparison
with existing conventional leg ulcer treatment.
Methods
A prospective, randomised controlled, open-labelled
clinical trial was carried out in the Hospital of Lithuanian
University of Health Sciences Kaunas Clinics from July
2014 to May 2018. The study was approved by the
Ethics Committee of both Kaunas Regional Biomedical
Research and Lithuanian University of Health Sciences
Hospital Kauno Klinikos.
The effectiveness of the treatment was assessed by
© 2019 MA Healthcare ltd

and systemic leg ulcer treatments, sometimes additional
treatment methods have to be applied to treat the
wound, such as synthetic ECM, biological tissue
substitutes, recombinant growth factors, stem cell
therapy and others.14,15,18
percent proportion of completely healed hard-to-heal
wounds (defined as 100% re-epithelialisation) and
wound healing progress (wound size reduction,
granulation formation) at the end of the eight-week
treatment protocol. In addition, microbiological wound

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Table 1. Inclusion and exclusion criteria

Inclusion criteria

Patients >18 years of age with diagnosed chronic leg ulcer (>3 months)

Wound area 2–200cm2 (minimum wound length 1.6cm in any direction)

Patient agrees to donate blood in order to prepare autologous platelet-rich plasma

Patient able to tolerate compression therapy

Exclusion criteria

Pregnant or breastfeeding woman

Patients with hypersensitivity and/or allergy to any of the components of treatment product

Acute local or systemic infection

Patients with clinically significant leg ischaemia (ankle-brachial pressure index <0.6)

Pressure ulcers as a type of chronic wound

Autoimmune diseases such as rheumatoid arthritis, lupus erythematosus, Hashimoto thyroiditis

Uncontrolled diabetes: HbA1c level >10%

Haematologic diseases or coagulopathies such as anaemia (Hg <60g/dl), thrombocytopenia (<180x109/l) impaired coagulation etc.

Heavy smokers (>20 cigarettes per day)

Patients with osteomyelitis or exposed nonviable bone in the bed of the wound

Patients having chemotherapy or using corticosteroids within one month before inclusion

Any other disease which could have influence on the study results such as terminal renal insufficiency, tuberculosis, acute severe hepatitis etc.

Fig 2. Treatment of the autologous platelet-rich plasma (PRP) group patients. Autologous PRP gel preparation (a).
Autologous PRP gel ready for topical application (b). Autologous PRP gel + primary paraffin impregnated dressing and
secondary dressings applied on the wound (c). Short-stretch compressive bandages for lower limb compression therapy (d)

a b

c d
© 2019 MA Healthcare ltd

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 practice

Fig 3. Treatment of the control group patients. Primary paraffin-impregnated dressing and secondary dressings applied
on the wound (a). Short-stretch compressive bandages for lower limb compression therapy (b)
a b

evaluation (wound swab culture) was also assessed
before, during and after the treatment. As there were
neither local nor systemic signs of infection, patients
with positive swab tests were not excluded from the
study and the treatment was continued as per protocol.
During the study period, over 200 patients with leg
ulcers were registered for a plastic surgery consultation.
Their eligibility for inclusion in the study was assessed
during the consultation (screening visit). The majority
of the patients were not included in the study due to

Table 2. Detailed study protocol

Data collected Screening Inclusion visit Treatment visit End of treatment visit
visit (D0) (TV1–TV3) (ETV); Day 56±2

Examination if patient eligible for study x

General information of the patient (complaints, anamnesis) x

Signed informed consent x

Baseline information (age, gender, smoker, non-smoker etc.) x

Inclusion and exclusion criteria x x

Randomisation x

Concomitant medication x x x

Clinical examination (ABP, etc.) x x x

Biological analysis (microbiological wound swabs, blood tests) x x x

Study wound status x x x

Peri-wound skin status x x x

Treatment evaluation

Effectiveness x x x

Wound pain x x x

Wound complications x x x

Acceptability x x

Adverse events x x

Photographs x x x

Treatment application x x
© 2019 MA Healthcare ltd

Treatment observance x x

Reason for drop-out x

D0—day 0; TV1–TV3—treatment visit 1–treatment visit 3; ETV—end of treatment visit; ABP—ankle-brachial pressure

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Table 3. General characteristics of the study population

Characteristic aPRP (n=35) Control (n=34) Total (n=69) p-value

Sex, n (%); female/male 17 (48.6)/18 (51.4) 17 (50.0)/17 (50.0) 34 (49.3)/35 (50.7) *p=0.906

Age, mean (SD) 62.23 (14.72) 68.01 (14.89) 65.08 (14.98) †p=0.109

BMI (kg/m2), mean (SD) 34.3 (7.2) 32.0 (9.0) 33.2 (8.2)
‡p=0.078

Median 31.5 33.2 29.9

Smoking, n (%) 6 (17.1) 1 (2.9) 7 (10.1) §p=0.106

Health status, n (%)

Excellent 1 (2.9) 0 1 (1.4)

Good 8 (22.9) 8 (23.5) 16 (23.2)

χ2=1.207,
df=3, p=1.0
Intermediate 23 (65.7) 24 (70.6) 47 (68.1)

Poor 3 (8.6) 2 (5.9) 5 (7.2)

Mobility limited, n (%) 23 (65.7) 21 (61.8) 44 (63.8) 0.733

aPRP—autologous platelet-rich plasma; *Chi-square test; †Student t-test for equality of means; ‡ Non-parametric Mann-Whitney U test; § Fisher’s exact test;
SD—standard deviation; BMI—body mass index; χ2—Chi-square criterion; df—Degrees of freedom

ineligibility for the study criteria (Table 1). Patients
included in the final data analyses were divided into
two groups: autologous PRP group and a control
group (Fig 1).
The test product was autologous PRP gel which was
prepared by centrifugation from a small sample of a
patient’s peripheral blood (8ml). Platelets were isolated
using a certified system of medical devices, RegenKit-
BCT (RegenLab, Switzerland). During the inclusion visit
(day 0, D0) patients were asked to choose one of two
sealed envelopes. Based on the card pulled out of the
envelope patients were randomly allocated to the
autologous PRP or control group. At D0, patients in the
autologous PRP group, has autologous PRP gel applied
to their ulcer followed by a paraffin impregnated
dressing, secondary dressings and short stretch
compression bandages (Fig 2). Control group patients
statistical analyses were performed on a 5% significance
level (α=0.05) using the IBM SPSS Statistics,
version 22, software.
Results
A total of 69 patients took part in the study (35 in the
autologous PRP group and 34 in the control group).
According to patient sociodemographic data, general
health status and mobility, both study groups were
homogenous (Table  3). Evaluation of clinical
characteristics of both study groups at the beginning of
the treatment revealed that there were no statistically
significant differences in the localisation of the ulcer,
Fig 4. Wound bed coverage with granulation tissue
100
Autologous platelet rich plasma Control
Wound bed coverage with granulation tissue (percentage)

received identical treatment but without the autologous

PRP gel (Fig 3). 90
91.73%
During the first treatment visit (TV1, day 14±2), the
80 84.29%
wounds were assessed repeatedly and the treatment was
renewed. The procedure was repeated again during 70
treatment visit 2 (TV2, day 28±2) and treatment visit 3
(TV3, day 42±2), which were scheduled every two or 60
three weeks. Secondary dressings were changed in the 56.03%
50
outpatient setting at a minimum of once a week as it
was stated in the treatment summary. Treatment was 40
46.14%
continued until complete wound closure occurred or
for a maximum period of eight weeks. The end of 30
treatment visit (ETV) was scheduled for 56±2 days from
the inclusion visit (D0). A detailed study protocol is 20
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provided in Table 2.
10
During the treatment visits, wound photographs were
taken and an Adobe Photoshop CS5 magnetic lasso tool 0
was used for the evaluation of the wound size reduction Inclusion visit (D0) End of treatment visit (ETV)
and wound bed coverage with granulation tissue. All

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Table 4. Clinical characteristics of the study population at the beginning of the treatment

Clinical characteristic APRP Control Total p-value

(n=35) (n=34) (n=69)

Recurrence, n (%) 13 (37.1) 10 (29.4) 23 (33.3) *p=0.906

Localisation, n (%)

Calf 27 (77.1) 30 (88.2) 57 (82.6)

χ2=1.477, df=2,
Ankle 6 (17.1) 3 (8.8) 9 (13.0)
p=0.531
Foot 2 (5.7) 1 (2.9) 3 (4.3)

Origin, n (%)

Venous/mixed 17 (48.6) 23 (67.6) 40 (58.0)

Arterial 2 (5.7) 1 (2.9) 3 (4.3)

Neurotrophic 6 (17.1) 3 (8.8) 9 (13.0)

χ2=3.63, df=5,
p=0.655
Trauma 7 (20.0) 6 (17.6) 13 (18.8)

Surgery 2 (5.7) 1 (2.9) 3 (4.3)

Burn 1 (2.9) 0 1 (1.4)

ABI, mean (SD) 0.98 (0.16) 0.98 (0.17) 0.98 (0.17) †p=0.843

APRP—autologous platelet-rich plasma; *Chi-square test; †Student t-test for equality of means; χ2—Chi-square criterion; df—degrees of freedom;
ABI—ankle-brachial index; SD—standard deviation

Table 5. Wound size reduction ulcer origin and ankle-brachial pressure (ABP) (Table 4).
Wound size APRP (n=35) Control (n=34) p-value*
Of note, the mean wound size of both study groups at
the inclusion visit did not differ significantly. During the
Inclusion visit (D0) 12.9 (16.6) 10.4 (11.3) p=0.683 eight-week treatment period, nine wounds (25.7%) in
mean (SD), cm²
the autologous PRP group and six wounds (17.6%) in the
End of treatment visit 6.2 (13.1) 6.9 (8.8) p=0.207 control group completely re-epithelialised by the end of
mean (SD), cm² the eight weeks, however, the difference was not
statistically significant (p=0.417). Comparing the change
Wound size reduction 6.8 (52.4%) 3.48 (33.4%) p=0.003
(Wound size before the in wound size during the study, significant wound size
treatment—after the reduction in both groups was observed (autologous PRP
treatment), mean (%), cm² group p<0.001; control group p=0.004). Comparing the
APRP—autologous platelet-rich plasma; D0—day 0; SD—standard deviation; *Mann-Whitney U test
wound change between the two groups after eight weeks,
we found that a larger area of the wound area
re-epithelialised in the autologous PRP group compared
Table 6. Microbiological evaluation of the wounds with the control group, 52.4% versus 33.4%, respectively;
Wound size APRP (n=35) Control (n=34) p-value* p=0.003 (Table 5). Significant wound bed coverage with
granulation tissue was observed in both study groups
Wound infection Two cases: Two cases: during the treatment. Data analysis revealed autologous
(occurrence 1—Pseudomonas Pseudomonas
during the aeruginosa; aeruginosa
– PRP superiority compared with conventional treatment
treatment) 1—Staphylococcus aureus (p=0.011) (Fig 4).
The most common bacteria found in wounds were
Positive swab test 21 (60.0%) 19 (55.9%) p=0.729
Staphylococcus aureus and Pseudomonas aeruginosa. Study
at the beginning
of treatment (D0) results on the microbiological changes of the wounds
revealed that treatment with autologous PRP had a higher
Positive swab test 15 (42.9%) 8 (23.5%) p=0.024 percentage of bacteria in the wound bed at the end of the
at the end of
treatment, compared with conventional treatment (Table
treatment
6). However, despite the fact that bacterial contamination
Most commonly Staphylococcus aureus Staphylococcus was more frequent in patients in the autologous PRP
© 2019 MA Healthcare ltd

isolated bacteria aureus group at the end of treatment compared with conventional
in wound cultures –
Pseudomonas aeruginosa Pseudomonas treatment, higher wound bed contamination did not
aeruginosa relate to a higher incidence of wound infection as in both
groups two patients developed wound infection (p>0.05).
APRP—autologous platelet-rich plasma; *Pearson Chi-Square test; D0—day 0
There were no severe adverse events during or after the

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 practice
treatment. In both study groups, two cases of clinically
significant infection were observed. All patients with
signs of infection were withdrawn from the study and
aetiopathogenetic treatment was initiated (antibiotics
were prescribed and the dressing technique altered).
A case of cephalic vein phlebitis was detected in the
autologous PRP group, which was directly related to
venepuncture from taking blood for autologous PRP
preparation. Moreover, one patient in the control group
refused to continue treatment and was withdrawn from
the study. Treatment with autologous PRP was
considered safe as the incidence of adverse events was
not higher than that observed in treatment with
conventional dressings.
Discussion
Use of autologous PRP is based on a regenerative
medicine concept of enhancing wound healing and is
associated with molecular (growth factors) as well as
cellular wound enhancement mechanisms.28,29 It has
been used for the past two decades in various fields of
medicine, most frequently in maxillofacial and
orthopaedic surgery.21,26 However, there are limited
scientific publications in the field of hard-to-heal leg
ulcers. Moreover, those studies are heterogenic using
different research methods, small sample sizes, various
autologous PRP preparation methods and widely diverse
evaluation parameters.
Previous studies on autologous PRP application in the
treatment of diabetic foot ulcers (DFU) showed
promising results. According to the study by Jeong et
al.29 of 110 patients, (52 in the autologous PRP group
and 48 in a control group), complete wound healing
was achieved in 79% of the autologous PRP group
patients compared with 46% in the control group
during the 12-week treatment protocol. Similar results
were published by Driver et al.,30 where complete
healing of DFUs was noticed in 83.1% of the autologous
PRP group patients compared with 42.1% of patients in
the control group. However, according to previous
clinical trials and meta-analyses, there is no clinical
evidence to support the benefit of autologous PRP in the
treatment of venous leg ulcers (VLU).27,31,32
Our study dealt with patients with hard-to-heal leg
ulcers of various aetiology. Most of the patients had
venous/mixed ulcers. Comparing the results of wound
size reduction between inclusion visit and end of
treatment visit, a greater reduction in wound size was
observed in the autologous PRP group versus the
control group.
More promising results in the treatment of leg ulcers
of various aetiology were published by Anitua et al.33 in
their pilot study; during the eight-week treatment
protocol, the wound size reduction was 72.9% in the
autologous PRP group whereas it was only 21.5% in the
control group. However, it was a small sample size study
including only 15 patients (eight in the autologous PRP
group and seven in the control group). Another
prospective randomised clinical trial including patients
666
with leg ulcers of various aetiology was published by
Knighton et al., 34 which reported a wound
re-epithelialisation of 81% in the autologous PRP group
at the end of the study, compared with 15% in the
control group. However, in their study, Krupski et al.35
did not find any additional benefits of autologous PRP
over conventional therapy. In fact, they noticed that
wounds treated with autologous PRP increased in size
at the end of treatment. The main limitations of these
studies evaluating various hard-to-heal leg ulcers are
associated with their differing study protocols,
autologous PRP preparations and interpretations of the
results, as well as their small sample sizes.
Another important objective in the field of treatment
of hard-to-heal wounds, in addition to wound size
reduction, is wound bed coverage with granulation
tissue, which signals the wound moving from the
inflammatory phase to the proliferation phase. Once
the wound bed is covered with granulation tissue,
positive conditions for wound healing, including
surgical treatment such as skin grafting, are created.
Based on the results of our research, the mean wound
bed covered with granulation tissue in the autologous
PRP group was smaller (46.1%) during the inclusion
visit compared with the control group (56.0%). Thus,
the difference was not statistically significant. However
at ETV, we found that the difference in wound bed
coverage with granulation tissue was significantly
higher in the autologous PRP group. In the experimental
in vivo animal studies conducted by Badis et al.36 and
Jee et al.,37 increased granulation tissue formation was
also observed in the autologous PRP group. These
findings support the idea that various growth factors
excreted by platelets stimulate angiogenesis and
fibroblasts as well as induce the granulation
tissue formation.21–27,38
According to recent studies and a systematic review
by Conde-Montero et al.27 there is no data that
autologous PRP application on the ulcer is associated
with increased risk of infectious complications.27,39 Our
study results confirm this statement. However, at the
end of the eight-week treatment, we found that patients
treated with autologous PRP were more commonly
associated with bacterial contamination of the wound
bed based on results from periodical wound swabs.
Limitations
The study had some limiting factors. it was a single-
blinded study with a relatively small sample size, and
wounds were of different aetiology, which all may have
influenced the final results of the study. A double-
blinded, multicentre clinical study involving a higher
number of patients is recommended.
© 2019 MA Healthcare ltd
Conclusions
The use of autologous PRP gel to treat various hard-to-
heal leg ulcers revealed promising clinical results during
the eight‑week study period compared with
conventional treatment. In particular, the wound size
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reduction and granulation tissue formation showed
superior results in the autologous PRP group compared
with the control group. Although autologous PRP
application was associated with more frequent wound
bed contamination by microorganisms, there is no
clinical evidence that it would cause significant adverse
events or complications more than existing
conventional treatment. Large sample size, multi-
central prospective investigations with single approved
treatment protocol and a long patient follow-up period
should be performed to define the rationale of
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Reflective questions
●● Why is understanding the wound bed environment as important as finding the
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●● What is the rationality of using autologous platelet-rich plasma (PRP) in the
wound treatment scheme?
●● What could be the causes of higher wound bed contamination in patients
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