|Year : 2019 | Volume
| Issue : 2 | Page : 109-114
Efficacy of platelet-rich plasma in acne scars
Anirudha D Gulanikar, Renu Vidholkar
Department of Dermatology, MGM Medical College and Hospital, Aurangabad, Maharashtra, India
|Date of Web Publication||15-Jul-2019|
Department of Dermatology, MGM Medical College and Hospital, Aurangabad, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Platelet-rich plasma (PRP) is an autologous preparation which contains a large amount of platelets concentrated into a small volume of plasma. PRP provides various growth factors which aid in quick wound healing. It is used as an adjuvant therapy for acne scars. Thus, in this prospective study, the efficacy of PRP as single modality of treatment for acne scars was evaluated. Methods: Thirty patients of Grade 2 and 3 acne scars according to the Goodman and Baron's qualitative acne scar grading system and Fitzpatrick Skin Type IV and V received six sittings of PRP at an interval of 1 month and followed up for 3 months after the completion of six sittings. Patients were assessed for the improvement in the scar grade, 1 month after the last sitting. Pre- and post-treatment comparative photographs and patient's and physician's satisfaction score were used to assess the results. Results: All the types of scars showed response in terms of reduction in size. Rolling scars responded better to PRP as compared to boxcar and ice pick scars. Estimation of improvement with Goodman and Baron's global qualitative acne scarring system showed that out of 30 patients with Grade 2 and 3 acne scars, 50% showed improvement in terms of acne scar grading at the end of the treatment. Among 25 patients with Grade 3 scars, 15 patients (60%) showed improvement by one grade. Adverse effects were mild being limited to transient pain, erythema, edema, and hyperpigmentation. Conclusion: The current study introduces autologous PRP as a cost-effective, well-tolerated office procedure in the treatment of acne scars without serious side effects. Further studies are needed to be carried out to compare the results of this present study.
Keywords: Acne, acne scars, platelet-rich plasma
|How to cite this article:|
Gulanikar AD, Vidholkar R. Efficacy of platelet-rich plasma in acne scars. Clin Dermatol Rev 2019;3:109-14
| Introduction|| |
Acne scarring occurs subsequent to visible resolution of inflammation caused by acne. It may occur regardless of the severity of acne, especially when an effective treatment is delayed., As most of the acne scars appear on the face, it is a major cosmetic concern for a patient and presents a challenge to a dermatologist due to lack of effective treatment modalities., Although many treatment modalities are currently being used, they have shown improvement to a limited extent with possible side effects. This being the reason that newer modalities of the treatment are constantly being tried upon. However, with the advent of platelet-rich plasma (PRP) therapy for atrophic scars, a new avenue for the treatment of acne scars is being explored. The therapeutic use of autologous PRP is a relatively new biotechnology in the stimulation and acceleration of soft-tissue healing. Its procedural safety is well established due to its autologous nature. PRP provides various growth factors which aid in quick wound healing. PRP when injected into the damaged area causes mild inflammation. The basis of this process is local and continuous delivery of a wide range of growth factors such as platelet-derived growth factor, transforming growth factor beta, platelet-derived epidermal growth factor, platelet-derived angiogenesis factor, insulin-like growth factor 1, and platelet factor 4 and proteins. All of these stimulate the physiological wound healing and reparative tissue processes.
In existing studies, PRP is used as an adjuvant for acne scars with other modalities such as microneedling, lasers, Vitamin C, and fat grafting., All these studies found that PRP was useful as an adjuvant therapy in the treatment of scars.,,,,, As efficacy of PRP alone in acne scar was not studied, our aim was to evaluate the result of PRP in Grade 2 and 3 acne scars.
| Methods|| |
A total of 43 patients belonging to Grade 2 and 3 acne scars and Fitzpatrick Skin Type IV and V visiting the dermatology outpatient department in MGM Medical College and Hospital, Aurangabad, from January 2014 to January 2015 were included in the study. Last patient completed the follow-up in October 2015. Out of them, 13 dropped out and failed to complete the study; thus, the study finally included 30 patients with Grade 2 and 3 acne scars. Patients above 18 years of age and with facial acne scars which disappeared after stretching were included in the study. Duration of scars was 3–8 years. Exclusion criteria consisted of patients with a history of bleeding disorders or anticoagulant medication, hemoglobin <10 g/dl, platelet count <105/μL, presence of active acne on face or infection anywhere in the body, keloid tendency, patients on cancer chemotherapy, pregnant or lactating women, and patients with a history of taking analgesics within 1 week before procedure. Patients were screened for human immunodeficiency virus and hepatitis B and C.
Thorough history of each patient was taken including demographic history, disease history – age of onset, frequency, duration, and presence of postinflammatory hyperpigmentation – treatment history, family history, and personal history. Clinical and dermatological examination was performed and grading of the acne scars was done according to the Goodman and Baron's qualitative global acne scarring grading system [Table 1]., Patients were explained in detail about the procedure, time required, possible side effects, and prognosis of the treatment. Procedure was done free of cost for all the patients excluding the charges for medications and investigations. Patients had undergone six sessions of PRP treatment at monthly interval. The procedure was standardized for spin time and revolutions per minute (RPM) at room temperature to get the minimum fourfold rise in platelet count from the baseline. Written informed consent was obtained and complete blood count including baseline platelet count was performed using an automated machine. Digital photographs of the patients were taken at the start of treatment and at the start of each session. Area of interest was painted with povidone iodine and cleansed with spirit before procedure and then was anesthetized using a thick application of topical anesthetic cream (combination of prilocaine 2.5% and lignocaine 2.5%) under occlusion for about 45 min before the procedure.
Twenty to thirty milliliters of autologous whole blood was collected from the median cubital vein and pure PRP (P-PRP) (according to the classification proposed by Ehrenfest) was prepared using a special sterile vacutainer tube containing an anticoagulant acid citrate dextrose-A. PRP was obtained manually by a two-step procedure using a centrifuge machine (Remi R4-C, serial number: HFLC-3995). First spin was performed at 1000 RPM for 12 min at room temperature. It was done to separate plasma with platelets and white blood cells from red blood cells (RBCs). RBCs being heavy settled down at the bottom. The plasma was gently aspirated from each tube and was transferred to a second tube (plain vacutainer bulb without anticoagulant). Second spin was performed at room temperature at the rate of 2000 RPM for 5 min, thus obtaining a two-part plasma. Upper two third, being poor in platelets, was platelet-poor plasma (PPP) and lower one third, being rich in platelets, was PRP. PPP was first gently aspirated to avoid its mixing with PRP and was then discarded. Residual PRP was then aspirated and was transferred into a sterile uricol bulb and its quantity was noted. The platelets in PRP were counted with the help of automated machine. Platelets in PPP were also counted in initial few patients, and the count was found significantly lower than baseline (around 30,000/μL). The concentration of platelets in PRP was approximately 4–4.5 times that of the baseline.
There have been limited studies on concentration of platelets required for optimal wound healing. A higher platelet concentrate would yield a higher number of growth factors. According to a study by Rughetti et al., the platelet concentration and the resulting changes in the activity of human endothelial cells were found to be related in a bell-shaped manner. They demonstrated that the stimulation for proliferation of endothelial cells peaks at 1.25 × 106 and angiogenesis peaks at 1.5 × 106 platelets/mL, respectively. This signifies the fact that a PRP platelet count of 1 million/mL has become the working definition for therapeutic PRP.
Just before injecting, PRP was activated with calcium chloride (nelcium, 10%/ml, neon laboratory) in 1:4 proportion (1 ml of calcium chloride for 4 ml of PRP). However, PRP, when used in soft tissue, does not need to be exogenously activated, as collagen acts as a natural activator of PRP. PRP was then injected intradermally through a 30G needle (insulin syringe) deep to each scar going through normal skin, on both the cheeks. The technique used for injection was “linear threading and fanning.” The amount injected was sufficient to elevate the scar, and the end point was taken as blanching and elevation of the scar. The total amount injected was 1–3 ml depending on the number of scars. After injecting, the site was gently massaged and compressed for a few seconds to control the bleeding. Ice pack was put when required. Topical antibiotic cream (fusidic acid 2% cream) was applied to the treated area. The patients were given topical sunscreen. The patients were reviewed on the 3rd day and on the 7th day for any side effects. All the patients were followed up monthly for 3 months after completion of six sittings.
Assessment of the patients
All the patients were assessed for the side effects such as erythema, edema, pain, hyperpigmentation, and bleeding during or after the procedure as well as for the development of active acne lesions during the treatment. Duration of each one of them was noted. At the end of the treatment, patients' scars were again graded according to the Goodman and Baron's qualitative acne scar grading system and were compared with the acne scar grade at the beginning. All the patients were evaluated 1 month after the last session. All the patients were asked to score the result of treatment subjectively from zero to four (patient's satisfaction score) [Table 2].
Patients were also evaluated by us subjectively and given score from zero to four using same scale (physician's satisfaction score)[Table 3].
| Results|| |
This study included 30 patients with facial acne scars. They were treated with monthly injections of PRP for 6 months and followed up for 3 months posttreatment. In our study, males (63.3%) outnumbered females (36.7%) forming a ratio of 1.72:1. Most of the patients belonged to the age group of 25–30 years (40%) with an equal number of patients in married and unmarried group and 53.3% patients were into an indoor job. According to Fitzpatrick classification of skin types, 24 patients (80%) belonged to Type IV and six patients (20%) belonged to Type V. None of the patients belonged to Type I–III and VI.
It was found that the average baseline count of all the 30 patients was 2.51 lacs/mm3. When platelet count was done again after preparation of PRP, it was observed that count in PRP was increased by 4–6-fold of the baseline. Most of the patients had mixed type of atrophic acne scars. In the present study, ice pick scars (48.4%) dominated followed by boxcar (26.2%) and rolling scars (25.4%).
PRP showed an improvement in all types of scars in terms of reduction in scar size. On visual analog scale, rolling scars responded better to PRP as compared to boxcar and ice pick scars. Estimation of improvement was done with Goodman and Baron's qualitative acne scar grading system. When scar grade at the end of the study was compared with that of before the treatment, it was observed that out of 30 patients, 25 patients (83.3%) had Grade 3 scars and five patients (16.7%) had Grade 2 scars before the start of the treatment. At the end of treatment, it was found that 10 patients (33.3%) had Grade 3 scars while 20 (66.7%) had Grade 2 scars (P < 0.0001) which was statistically significant [Table 4].
Patient satisfaction score
On asking the patients to score their satisfaction level from zero to four, 16 patients (53.3%) gave score as three (very good) followed by 14 patients (46.7%) patients who gave score as two (good) [Table 5].
Physician's satisfaction score
Physician's subjective satisfaction score was obtained considering photographs, patient examination, and cost and manual efforts required for the procedure. At the end of the treatment, 17 patients (56.7%) were scored two (good) while nine (30%) were scored one (mild) and four (13.3%) were scored three (very good). None were scored four (excellent) [Table 6].
When acne scar grades at the end of the study was compared with that of before the treatment, it was observed that out of 30 patients, 25 (83.3%) had Grade 3 scars and five (16.7%) had Grade 2 scars before the start of the treatment according to the Goodman and Baron's qualitative acne scar grading system. At the end of treatment, it was found that ten (33.3%) patients were in Grade 3 while 20 (66.7%) were in Grade 2 (P < 0.0001; highly significant). Mild and transient side effects were noted. All patients experienced treatment-related pain during the procedure, but majority of patients did not complain of significant pain after completion of session. All patients had reported mild erythema and edema which lasted for about 1 day in majority. We noted hyperpigmentation on both cheeks of only one patient after completion of the fourth sitting. The hyperpigmentation could be attributed to postinflammatory changes or sun exposure; the exact cause could not be elicited. It resolved in 3 weeks with a topical corticosteroid (desonide 0.05% cream) and atopical sunscreen. The patient resumed treatment after 1 month.
| Discussion|| |
Facial acne scars are not only a major cause of cosmetic concern but also have a significant psychological impact on the patients. Although many techniques are currently being used, they all have varying degree of success and associated side effects. The main function of PRP is to deliver growth factors in high concentration to sites requiring wound healing. Whether it is used in bone grafting procedures or in dental implants, PRP is already known as an “enhancement factor.” Even in dermatological procedures, PRP is being used to augment the results in procedures which are already a primary modality of treatment for conditions such as acne scars and androgenetic alopecia. PRP is also used in leg ulcers to fasten the healing process and is becoming a popular treatment option for facial rejuvenation.
All these positive results of it being a supportive therapy prompted us to study its role as a primary treatment option in acne scars.
The studies showing the effect of PRP as a single treatment modality for acne scars are lacking. Thus, in this prospective study, the efficacy of PRP as single modality of treatment for acne scars was evaluated.
In our study, we found that all the types of scars having varying duration showed response to PRP injections in terms of reduction in size [Figure 1], [Figure 2], [Figure 3]. On visual analog scale, rolling scars responded better to PRP as compared to boxcar and ice pick scars. Fifty percent of patients showed improvement in terms of acne scar grade. As only visual analog scale was used in our study which is not a completely reliable method, further studies using scientific methods measuring depth and size of scars are required to confirm the results. PRP is a completely safe procedure. We only noted minor and transient side effects such as erythema and edema lasting for 1 day in majority. Only one patient developed hyperpigmentation after the fourth sitting which resolved with the treatment.
Pain after completion of procedure was not significant in majority. No patient reported significant bleeding. None developed active acne during the treatment.
| Conclusion|| |
Although comparative studies using only PRP are lacking, the present study may provide evidence supporting the clinical efficacy of autologous PRP in treating acne scars. Preparation of PRP is time-consuming and tedious, but it is cost-effective and quite a safe, well-tolerated procedure. Further studies are required to standardize the preparation process of PRP including factors affecting yield of PRP, to optimize the platelet count in PRP for the best results, and to find the efficacy of PRP in all types of scars.
- Lack of control group
- Lack of similar studies for comparison
- Lack of long-term follow-up.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]