The evolution of platelet-rich plasma: A 70-year-old history

INTRODUCTION

Platelet-rich plasma (PRP), popularly known as the “vampire facial,” has gathered significant public interest in recent years for its skin rejuvenation effects. It is currently one of the most promising treatments in regenerative medicine. It has an application in many different fields of medicine, including esthetic dermatology, orthopedics, sports medicine, and surgery. Although PRP gained popularity primarily for its application in skin aging, the therapy has been used for many years. In fact, PRP is 70 years old and has a steadily growing number of applications in various fields of medicine. PRP is a particularly promising method in the world of hair and scalp conditions.^[1,2]

HISTORY OF PRP

In 1842, Donné was the first to discover structures other than erythrocytes and leukocytes in the blood.^[3] Julius Bizzozero was the original proponent of the term for the newly discovered structures “le piastrine del sangue” – the literal translation from Italian means “blood plates.” In 1882, the same author described the role of platelets in blood clotting in vitro and their involvement in thrombosis in vivo. Bizzozero was also the first to find that the vascular wall had an inhibitory effect on platelet adhesion.^[4] Megakaryocytes, which are precursors of platelets, were next discovered by Wright.^[5] Starting as early as the 1940s, embryonic “extracts” composed of growth factors (GFs) mixed with cytokines were utilized to promote wound healing.^[6]

Following this trend, Eugene Cronkite introduced a combination of thrombin and fibrin in skin grafting.^[7] At the beginning of the 20^th century, citrates began to emerge as anticoagulants in the preparation of platelet concentrates. Their preparation was improved in the 1950s when soft plastic blood containers, called “EDTA Platelet Pack,” were created. The kit contained a plastic soft bag of ethylenediaminetetraacetic acid blood and allowed platelets, which were suspended in a small amount of plasma, to be concentrated by centrifugation.^[8-10] The term “platelet-rich plasma” was first introduced in 1954 by Kingsley to refer to the standard platelet concentrate for transfusion.^[11]

In the late 1970s, hematologists were the first to use PRP in the full sense of the term. They described PRP as plasma with a platelet count above that of peripheral blood. It should be noted that the therapy was originally used as a transfusion product to treat patients with thrombocytopenia.^[1] In the 1980s, PRP began to be used in the treatment of ulcers as well as in maxillofacial surgery due to the discovery of GFs. Their mitogenic, angiogenic, and hemotoxic properties, as well as their potent anti-inflammatory action, further contributed to the popularization of plasma.^[1] GFs are secreted by platelets and contribute to the regenerative action of plasma, thereby succeeding in repairing damaged tissues (e.g., skin ulcers).^[10,12] GFs were then discovered and named: In 1962, Cohen discovered epidermal GF (EGF), and platelet-derived GF (PDGF) and vascular endothelial GF were discovered in 1974 and 1989, respectively.^[2]

During this period, in 1972, Matras first used platelets “as sealants” during surgical procedures to achieve better blood homeostasis. In 1987, Ferrari first used PRP in cardiac surgery as an autologous source in blood transfusions, to reduce intraoperative blood loss, hematologic disorders of peripheral pulmonary circulation, and subsequent use of blood products.^[1,2]

Maxillofacial surgery is another area where PRP is a popular treatment methodology. In 1999, PRP began to be used in dental implantology^[12,13] to improve graft incorporation into jaw reconstructions, dental implant placement, and stimulation of bone regeneration. PRP began then to be used in maxillofacial surgery as platelet-rich fibrin. Fibrin has potential adhesion and hemostatic properties, and PRP, with its anti-inflammatory characteristics, stimulates cellular proliferation.^[12,13]

The use of PRP in the plasmapheresis process to improve bone regeneration was described in 1999 by Anitua. After observing the beneficial effects of PRP, he reported the effects of this blood fraction on chronic skin ulcers, dental implants, tendon healing, and sports injuries.^[13] Thus, in the early 2000s, PRP was used primarily in the musculoskeletal field and in sports injuries.^[1,14] PRP is still actively used today for the treatment of degenerative orthopedic diseases, tendon, ligament, muscle, and cartilage healing.^[14]

Shortly after, in the early 2000s, the method was introduced into the field of dermatology for tissue regeneration, wound healing, scar revision, and skin rejuvenation. Wounds have a dominant pro-inflammatory biochemical environment that impairs the healing of chronic ulcers. In addition, this environment is characterized by high protease activity, which reduces the effective concentration of GFs. PRP is used as an alternative for the treatment of non-healing wounds as it is a source of GFs and therefore has mitogenic, angiogenic, and hemotoxic properties.^[15]

In esthetic dermatology, a study conducted in vitro shows that PRP can stimulate fibroblasts in the dermis and increase type I collagen synthesis, induce neoangiogenesis, and form adipose tissue.^[16-18]

As platelet-based therapies have evolved, so too have their preparation protocols – ranging from variations in centrifugation steps and the introduction of diverse commercial kits to the use of different activators and attempts at standardization – all of which significantly influence the concentration, composition, and clinical efficacy of the final product.^[7] Figure 1 shows the standard procedure of whole blood collection from the antecubital vein using venipuncture technique, and then centrifuging the blood to obtain PRP with a commercial kit with separation gel.

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Figure 1:

Collection and separation of platelet-rich plasma: Venipuncture and post-centrifugation plasma stratification.

Export to PPT

Today, PRP is widely used in the improvement of burn, postoperative, and acne scars. Alone or in combination with other techniques, the method appears to improve skin quality and increase collagen and elastic fibers. In 2006, the use of PRP in the treatment of hair and scalp began for androgenetic alopecia and in hair transplantation.^[1] The therapy is seen as a potential therapeutic tool to stimulate hair growth and is perceived as a new method for the treatment of androgenetic alopecia and alopecia areata. It is now considered a potential adjuvant treatment for cicatricial alopecias such as frontal fibrosing alopecia, lichen planopilaris, and central centrifugal cicatricial alopecia.^[19-21] PRP has been used to rejuvenate wrinkles and aged skin for years. In studies for facial skin rejuvenation, PRP has been shown to improve texture, wrinkles, and facial volume. PRP increases dermal collagen levels not only by GFs but also by skin needling.^[22] The use of PRP has evolved significantly over the decades, with its application expanding across multiple medical specialties. A chronological overview of PRP’s introduction in various fields is summarized in Table 1.

Recent advancements in regenerative dermatology have led to the development of next-generation PRP-based therapies such as GF concentrate (GFC) and exosome-rich formulations, which aim to enhance and standardize the regenerative potential of autologous blood derivatives. GFC therapy isolates and concentrates key PDGF, offering a more consistent and potent regenerative stimulus compared to conventional PRP.^[23] Other medical fields in which the use of PRP finds significant success are pediatric surgery, gynecology, urology, plastic surgery, ophthalmology, reproductive medicine, and the latest trends, which are in the use of therapy for erectile dysfunction.^[1] A summary of evidence-based indications for PRP therapy is presented in Table 2.^[14,24]

CONCLUSION

PRP therapy has a 70-year history. It originated in transfusion medicine and is used to treat thrombocytopenia as a platelet concentrate. Since then, PRP has many applications in various fields of medicine and is particularly promising for regenerative, esthetic dermatology as well as conditions of the hair and scalp.