Platelet-Rich Plasma Should Not Be Practised In The Medical Field

            Vampire facelift is one of the treatments prevalently chosen by Hollywood celebrities nowadays. Kim Kardashian, Rupert Everett and Anna Friel are some of them, as reported in The Telegraph newspaper by Chalmers (2014). The name “Vampire Facelift” was established by Dr. Charles Runels from Alabama in 2010, when Vampire Diaries and Twilight Saga were a huge phenomenon at that particular time. Widely known as platelet-rich plasma (PRP) among the physicians, it consists of a portion of plasma fraction of autologous blood having a platelet concentration above baseline (Lacci & Dardik, 2010).

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A study conducted by Ferrari et al. (as cited in Sampson, Gerhardt & Mandelbaum, 2008) revealed that the first time PRP was used during an open heart surgery was to avoid excessive transfusion of homologous blood products. In early 1990s, many doctors started to practice PRP in other areas of expertise such as maxillofacial dental, periodontal surgery, cosmetic surgery and skin grafting due to the positive improvements that were shown in several reports (Alderman, 2010).

            PRP was believed to function as a tissue sealant and drug delivery system with the platelets initiating wound repair by releasing locally acting growth factors via ?-granules degranulation (Lacci & Dardik, 2010) because it contains a number of proteins, cytokines and other bioactive factors ? which was concluded as a modern version of prolotherapy (Alderman, 2010). According to Alderman and Alexander (2011), prolotherapy is a nonsurgical treatment which stimulates healing and short for “proliferation therapy”. It is also known as nonsurgical ligament and tendon reconstruction, or regenerative injection therapy (Alderman & Alexander, 2011). PRP was also believed in its ability to reduce the risk of having any appalling side effects including infection or allergic reaction because the source of the injected substance is from the patient’s own body (Rizk, n.d.).

This has shown that the use of PRP in medical field has been acknowledged for a long time, whether it is in a form of liquid injection or gel-like structure, and was recently pointed out by Marwah, Godse, Patil and Nadkarni (2014) that it has attracted attention in the field of dermatology. People have started to give it a try in order to improve and rejuvenate their own skin for beauty. The UK’s Platelet Rich Plasma Specialist (2015) promoted the use of PRP instead of botox or dermal fillers as it gives the skin a more natural radiance and the effects last longer.

            In spite of all of these positive effects, has the use of PRP been approved clinically to not give any complications to the consumers? The question on PRP’s authenticity is still being argued, even among the specialists and physicians because there were no consensus that PRP or related treatments have meaningful benefit (Lazarovic, 2013). Lazarovic (2013) again emphasised it is highly recommended that the PRP treatment is to be restricted to precise clinical studies and not to be used in the general population. This is to avoid delivering improper treatments to the patients as it is still very unsure in terms of administration, dosage and side effects. Hence, platelet-rich plasma therapy should not be encouraged due to uncertainties of its results, treatment administrations and side effects that can harm the consumers.

Uncertainties of Platelet-Rich Plasma in Its Results

The variable and unpredictable results of PRP treatment have situated it in an uncertain position to be practised in medical field. It was also claimed to be nothing more than a mere expensive placebo. This idea has been confirmed by the findings of a few researches. As for the first case, a study was conducted by Margolis et al. (as cited in Lacci & Dardik, 2010) in investigating the effectiveness of platelet releasate (PR) in the treatment of diabetic neuropathic foot ulcers, 21% of the patients were treated with PR. The result shows that 43.1% of patients healed within 32 weeks, including 41% of patients not treated with PR treatment and 50% of patients treated with PR. However, there was a varying timing of PRP treatment as not all patients received 20 full weeks of the treatment. The percentage of healed patients also levelled off after 20 weeks, which means only little incremental continued healing after this time.

From another research finding, it is learned that the use of PRP in treating jumper’s knee was observed in a 6-months study (Kon et al., 2008). The study resulted in six men with complete recovery, eight with marked improvement, two with mild improvement and no improvement in four cases. Statistically, a significant improvement was observed. Lower results were only shown in patients who did not follow the post-procedure protocol. In the three of the failed cases, the patients did not follow the stretching and strengthening programme. In the fourth case, there was no improvement even after the lengthened programme and treatment. After six months, a surgery was conducted on him and intratendinous within the tendinous portion of a muscle calcification was found and removed. Calcification is one of the side effects that might follow around the injection site (Johnson, n.d.). This will be discussed in the later part. Nevertheless, the results of this written article was from a pilot study, thus the effectiveness of PRP could still be questioned because of the small sample size used.

Next, an article produced by University of Michigan claimed that the use of PRP to enhance bone regeneration has been documented in several cases (Wang & Avilia, 2007). However, a recent study on bone ingrowth and vascular supply using PRP has been conducted by Cinotti et al. (2013) in experimental spinal fusion. Subjects of experiment were rabbits. The aim of the experiment was to create a bony bridge between the transverse processes of the vertebrae. Although some new bone growth was observed, none of the rabbits developed a full bony bridge. There was also no increase in vascular density. Hence, it is clear that PRP does not support in bone growth and vascularisation.

Moreover, in cases related to tissues, Randelli, Arrigoni, Ragone, Aliprandi and Cabitza (as cited in Maffulli et al., 2011) pointed out the use of PRP augmentation for “rotator cuff repair do not show improved functional outcomes when compared with a non-augmented repair at medium and long-term follow up”. This shows that uncertainty still exists due to its capability in yielding improved results. Although several authors advocated the use of PRP, the current literature on tissue engineering application for rotator cuff repair is scanty (Randelli, Arrigoni, Ragone, Aliprandi & Cabitza as cited in Maffulli et al., 2011).

In brief, the overall of PRP treatment provides such weak evidence. This is based on many of the case reports which were lacking in control. The weak evidence presented to support the increasing clinical use of PRP as a treatment for various injuries makes the validity and effectiveness of PRP uncertain.

Uncertainties of Platelet-Rich Plasma in Its Treatment Administrations

To this date, there is no article published on the most effective method in carrying out PRP treatment. Thus far, PRP has been administered on various locations of tendons, prepared through different form of methods, assisted by ultrasonography also known as ultrasound as it was being injected, approached by different techniques of injection and the necessity of growth factors in PRP.  

As for treatment administrations on the tendon or ligament, its effectiveness might vary as different tendon or ligament has different composition and structure; influenced by the location of the tendon or ligament, its function, and its nature of injury (Wilson, 2015). This can be seen in the difference of results of PRP treatment in jumper’s knee study by Kon et al. (2008) and rotator cuff tears study by Maffulli et al. (2011).

Moreover, from the preparation to the administration of PRP, all of those steps are crucial for an effective treatment. When preparing PRP, several procedures need to be carried out. One of the procedures is to centrifuge the PRP in order to produce high platelet concentration. A study was carried out by Kavitha et al. (2011) in determining the best method of preparing PRP. In general, the PRP needed to be centrifuged twice. The first centrifugation method that was carried out by Kavitha et al. (2011) was to start off with “hard spin” and followed by “soft spin”. The hard spin and soft spin were referred to the speed of centrifugation. As for the second method, soft spin was used first, followed by hard spin. The later method showed higher mean number of platelet, but it was not known whether all of the present platelets were functional or not.

In another research finding, PRP was also administered through injection, especially in the treatment of plantar fasciitis. In several studies of treating plantar fasciitis, PRP was either injected with or without ultrasound guidance. Plantar fasciitis is the ligament that connects our heel bone to our toes (“Plantar Fasciitis ?Topic Overview”, 2014). In three selected successful studies, ultrasound guidance was used during injection (O’Malley, Vosseller & Gu, 2013; Kim & Lee, 2014; Wilson, Lee, Miller & Wang, 2014). However, it is unjust to say that the injection done without ultrasound guidance will show poor result as it has been declared in a study conducted by Kane et al. (2001) that the application of ultrasonography in treating plantar fasciitis did not show any advantage over the application of bone scintigraphy an imaging test used to diagnose abnormalities in bone.

Other than the use of ultrasonography in assisting the injection of PRP, the technique of injection itself might also contribute to the outcome of this study. Kalaci et al. (2009) reported that peppering technique of injection used has a superior effect over single direct injection. In peppering technique, the tip of the needle was maintained and was withdrawn slowly. It was then angulated and reinserted at another site to make different injection, thus stimulating some growth factors which help in tissue regeneration (Chiew, Ramasamy & Farahnaz Amini, 2016).

Next, the treatment of PRP on patients who suffered from osteoarthritis conducted by Ali Soliman Hassan, Abeer Mohamed El-Shafey, Ahmed and Mohamed Soliman Hamed (2015) shows that the percentage of living and essential cells might influence the effectiveness of PRP as they are proportional to the amount of growth factors present. This can be seen in younger patients and patients whose duration of disease was short.

In brief, the uncountable of unanswered questions in PRP research need to be solved, including the recommendations for administration of PRP and where it should be administered, the optimal concentration of platelets, the effect of different centrifugation speed to platelet behaviour, the present of growth factors and many more. Hence, further studies should be carried out before the PRP treatment can be deemed effective.

Uncertainties of Platelet-Rich Plasma in Its Side Effects

PRP has also been known to produce side effects, ranging from mild to severe complications. Side effects may only occur when certain properties mix with certain other properties. It has been documented that PRP caused flares as a post-treatment side effect. The deposition of calcium and the occurrence of scar tissue are possible, theoretically, although no report has been made on this. This usually happened around the injection site (Johnson, n.d.). In the case of PRP treatment, calcification might occur due to continuous inflammation. However, the deposited calcium could be treated by taking anti-inflammatory medicines, applying ice packs on the uncomfortable area, or even by removing the deposited calcium through surgery (Moore, Nall & Jewell, 2016).

Moreover, some doctors claimed that their patients experienced quite severe flares after receiving their PRP treatment. After carrying out several studies, it was understood that the red blood cells spilling over into the isolated concentrated platelets when preparing PRP was what caused the flare up. This red instead of amber in colour of PRP produces MMPs (Matrix Metalloproteinase), which was responsible for cartilage breakdown (Centeno, 2012).

Aside from the use of PRP by injecting into body parts, PRP is also used in gel form. In oral medicine field, PRP gel is commonly used. To form PRP gel, calcium chloride and topical bovine thrombin are used. The issue arose when the use of bovine thrombin developed an inhibitor to factor V, which resulted in a life-threatening coagulopathy. Coagulopathy is the impaired ability of blood to clot. One death has been recorded as the continuous bleeding could not be stopped (Cmolik, Spero, Magovern & Clark, 1993; Muntean, Zenz, Finding, Zobel & Beitzke, 1994; Landesberg, Moses & Karpatkin, 1998; Spero, 1993).

Therefore, the side effects of the application of PRP prove that it was not guaranteed that the use of PRP treatment would not bring any complications. In fact, it was found that the complication can also be life-threatening. More systematic and controlled studies need to be conducted in order to have a valid result, thus overcoming the side effects and ensuring the safety of using PRP.

In conclusion, despite some successes in the field of dermatology and tissue grafting the practice of platelet-rich plasma in medical field should not be encouraged due to several uncertainties of its results, treatment administrations and side effects; regardless of beautification or alternative for injuries treatment as it brings more ambiguity and risks than benefits from its effectiveness.

As mentioned earlier in our first main point regarding uncertainties of result, the case of effectiveness of platelet releasate (PR) in the treatment of diabetic neuropathic foot ulcers proved that not all patients were cured successfully. Some even managed to heal naturally without using PR. Next, in treatment administrations one of the methods that we have discussed is how centrifugation was carried out. The method which started off with soft spin and followed by hard spin showed higher mean number of platelet but it was not known whether all platelets present were functional or not. The use of PRP also has its side effects. In fact, one death has been recorded due to severe coagulopathy in oral medicine.

It is highly advisable for the patients who intend or are interested with any treatments which involve PRP to have a one-to-one consultation with their specialist. This is to give a better exposure for the patients in handling and preparing themselves with the post-treatment risks because even some of the insurance companies would not be responsible on any complications that might happen due to any treatments which use PRP.

From the Islamic perspective, the use of PRP in medical field especially for beautification is strictly forbidden (Nurhidayah Muhamad Sharifuddin, Nur Fadhilah Muhamad Apardi & Mohd Anuar Ramli, 2015). Allah has clearly stated in Surah Al-Nahl verse 115 “He has only forbidden to you dead animals, blood, the flesh of swine, and that which has been dedicated to other than Allah. But whoever is forced by necessity, neither desiring it nor transgressing its limit – then indeed, Allah is Forgiving and Merciful”.

 Most of the scholars had made a consensus that blood is considered to be a ??? impurities that caused ????? not accepted by Allah, if it is present which can affect Muslims’ deeds to become uncertified. Nevertheless, if one’s medical condition worsens and PRP treatment is said to be the best alternative or in the case of saving one’s life, thus it is permissible.

Therefore, it is important for us to acquire full information on the treatment that we will be having before taking any attempt on it, especially one which is not clinically approved or lack in sample because it cannot give us a complete assurance. As for PRP, the application is still very new; specifically in Malaysian medical field. Hence, the best way is to avoid it at all cost and find a medication or treatment which its benefits and effectiveness have been established.