Effectiveness and safety of topical autologous platelet-rich fibrin membrane with total contact cast versus perilesional injectable autologous platelet-rich plasma therapy with total contact cast in trophic ulcer due to leprosy: A randomised controlled trial

Introduction

Trophic ulcers caused by leprosy have a significant impact on a patient’s life by being non-healing in nature, increasing morbidity, affecting mental well-being and diminishing the quality of life. These ulcers develop due to increased pressure in some body parts like the sole, hand, etc., resulting from lack of sensation in those areas.¹ These trophic ulcers are difficult to treat and contribute to occupational and psychological morbidity leading to the stigma that is associated with the disease. With a vision of 90% reduction of grade 2 disability (G2D) in Global Leprosy Strategy by 2030, management of trophic ulcer, a common G2D, has become a priority.^2,3

Studies have documented that these ulcers heal if rest for sufficient time is given,⁴ albeit sufficient rest is a utopian concept for those living with leprosy who mostly are economically underprivileged and are daily wage earners. Thus, a plaster cast (below the knee) can be applied to hasten healing yet maintaining ambulation. Needless to say, any method which hastens the healing, can help patients to return to their normal personal and professional life.

A few novel methods, based on platelets, have been developed for the healing of leg ulcers. Autologous perilesional injectable platelet-rich plasma (PRP) and autologous platelet-rich fibrin membrane (PRFM) are two such platelet-based therapies effective in healing of trophic ulcers in a short period of time.⁵ Platelets assist in wound healing by providing a few growth factors such as transforming growth factor-β, platelet-derived growth factor, insulin-like growth factor-1, etc.⁶

Platelet-rich plasma is a first-generation platelet concentrate.⁶ It is separated by a two-spin centrifugation method.⁷ It is a labour-intensive procedure. Bovine thrombin and calcium chloride are required as anticoagulants. Platelet-rich fibrin membrane is a second-generation platelet concentrate which is prepared by single-spin centrifugation and without any artificial biochemical modification. It is more simplified, cost-effective, and less time-consuming than PRP separation. There is a fine and flexible fibrin network formation that is suitable for cytokine enmeshment and cell migration due to the formation of equilateral junctions. There is a slow release of growth factors over a period of at least 7 days. It speeds up ulcer healing because of slow polymerisation.⁶

There are studies which have evaluated the role of autologous injectable PRP or PRFM in trophic ulcer healing.^7,8 However, comparative studies between the two methods are very few. Thus, we aimed to compare the safety and effectiveness of PRP and PRFM in trophic ulcers due to leprosy.

Methods

The study was conducted as a unicentric, observer-blind, non-inferiority randomised controlled trial at a tertiary care rural hospital in Eastern India for a period of 2 years. Institutional Ethics Committee permission was obtained and written informed consent from each patient was taken. The trial was registered with the Clinical trial registry, India, and bears the registration number of CTRI/2021/09/036230.

Results

Out of the 64 patients screened, 52 patients with leprotic trophic ulcer were recruited and randomised equally into two groups. One patient dropped out (who did not come for any of the visits). So, the data of 51 participants (group A=26, group B=25) was analysed based on the LOCF strategy. The CONSORT flow diagram of study participants is shown in Figure 1.

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Figure 1:

Consolidated Standards of Reporting Trials (CONSORT) flow diagram of study participants.

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There was no significant difference between the groups with respect to age (p=0.737), gender (p=1.00), education (illiterate/literate) (p=0.199), occupation (unemployed/employed) (p=0.264), and income (above poverty line/below poverty line) (p=1.00). There was male predominance in both group A (M: F=17:9) and group B (M: F=17:8) subjects [Table 1].

There was no significant difference between the two treatment groups according to the duration of ulcer (p=0.069), the spectrum of leprosy (p=1.00), release from treatment (RFT) (p=0.668), and duration since the beginning of MDT (0.637) [Table 1]. Overall, the most common site of ulcer was the heel (27.5%) followed by the base of the great toe (21.6%) and the great toe (19.6%) itself (Great toe meant the plantar surface of the first phalanx of the foot. Base of the great toe meant the plantar surface of the first metatarsal region of the foot).

Baseline surface area was also found to be comparable in both the treatment groups (P = 0.631, Mann–Whitney test).

Significant reduction in surface area was observed from the first follow-up onwards, in comparison with baseline in both the PRP- and PRFM-treated groups (p<0.001, Friedman ANOVA followed by post-hoc Dunn test) [Figures 2 and 3]. However, intergroup comparisons at all the subsequent follow-ups showed no statistically significant intergroup difference in surface area [Table 2].

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Figure 2a:

Pre-treatment photograph with platelet-rich plasma.

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Figure 2b:

Post-treatment photograph with platelet-rich plasma.

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Figure 3a:

Pre-treatment photograph with platelet-rich fibrin membrane.

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Figure 3b:

Post-treatment photograph with platelet-rich fibrin membrane.

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There was no statistically significant difference in the percentage reduction of surface area between the two treatment groups at baseline and subsequent follow-ups. Intragroup change in percentage reduction of surface area was assessed by the Friedman test which shows a statistically significant difference (p<0.001), compared to baseline, in both the treatment groups. The result was further assessed by the post-hoc Dunn test to determine the follow-up or visit from which statistically significant change occurred. In both the groups, a statistically significant percentage reduction in surface area from baseline occurred from the first follow-up onwards. But, in group A, the percentage reduction at the second follow-up had no statistically significant difference from that of the first and third follow-ups; similarly, no statistically significant change was observed between the fourth and fifth follow-ups. In group B, there was no statistically significant change between the second and third follow-ups and also between the fourth and fifth follow-ups [Table 3].

The number of patients showing complete healing of the ulcer was six in group A (23.1%) and three in group B (12%). (Fischer’s test, p=0.465). Logistic regression analysis was done to find any association of variables in patients achieving complete healing of ulcers. Female gender was associated with faster healing than males (correlation coefficient −3.321). There was no significant association with age, occupation, baseline surface area, duration of ulcer, duration since the beginning of MDT, baseline haemoglobin or platelet count, and treatment with PRP or PRFM with complete healing of ulcers. [Table 4]. The different adverse events noted were painful foot swelling and nummular dermatitis in group A and painful foot swelling, callosity development, and maggot formation in group B. In group A, 24 out of 26 patients (92.31%) did not face any adverse event, whereas this figure was 22 out of 25 (88%) in group B (Fisher’s exact test: P= 0.668). The routine laboratory reports done at baseline and end of active treatment were within normal limits in both the treatment arms. The painful foot swelling was because of cellulitis and was treated successfully with antibiotics (amoxicillin and clavulanic acid 625mg three times daily for 7 days) in all the cases.

There was a significant decline in DLQI score from baseline at the sixth week (third follow-up visit) and tenth week (fifth follow-up visit) in both the treatment groups (Friedman test followed by post-hoc Dunn test) [Figure 4].

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Figure 4:

Reduction in DLQI from baseline at sixth week baseline and follow-up visits (third follow-up visit) and tenth week (fifth follow-up visit) in both the groups (treatment 1= platelet-rich plasma, treatment 2=PRFM).

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Discussion

Trophic ulcer is one of the common disabilities in leprosy. Plantar ulcers make the leprosy patients prone to stigmatisation which arises from both the self and the society. Leprosy patients with plantar ulcer need medical, social, psychological and vocational rehabilitation. So, treatment of plantar ulcers in leprosy with minimum resources is necessary for both the leprosy patients and the society.

A few novel methods have been developed for healing of trophic leg ulcers. Two of those are platelet-rich plasma therapy and PRFM. Application of total contact cast after these procedures hastens the wound healing. In this study, we compared the two methods of PRP+TCC versus PRFM+TCC in trophic ulcers due to leprosy.

For PRP preparation, we followed the protocol used by Saha S et al.⁷ Some authors prepared PRP in somewhat different ways. Sarvajnamurthy S et al.¹¹ prepared PRP by centrifugation of citrate-mixed blood at 5,000 rotations per minute for 15 minutes followed by a second spin of 2,000 rotations per minute for 5–10 minutes. Bansal S et al.⁶ prepared PRP centrifugation of citrate-mixed blood at 1,300 rotations per minute for 10 minutes followed by a second spin of 2,000 rotations per minute for 10 minutes. Calcium chloride (0.45 mL) (instead of 0.8 mL calcium gluconate) was used to form PPP gel by Sarvajnamurthy S et al.¹¹ Bansal S et al.⁶ also mentioned the use of calcium chloride (instead of calcium gluconate) for making PPP gel.

Our method of PRFM preparation was almost similar to the method used by Jagati A et al.⁹ except that paraffin-impregnated gauze was used instead of collagen sheet to make it more cost-effective. Nagaraju U et al.⁸ collected 10 mL of blood and centrifuged it at 3,000 rotations per minute for 10 minutes. Bansal S et al.⁶ mentioned the same rate of centrifugation as Nagaraju U et al.⁸ Collagen sheet was used as a scaffold by Jagati A et al.⁹Gauze compression followed by a secondary dressing was used as covering material by Nagaraju U et al.⁸ A comparison between the resources needed in PRP and PRFM is given in Table 5.

In our study, the two treatment groups were comparable regarding the clinico-demographic factors. Most of the patients were RFT and received MDT-MB. Overall, the most common site of ulceration was the heel followed by the base of the great toe.

At baseline, the study groups had analogous surface area of the ulcer. In the subsequent follow-ups, there was no statistically significant intergroup difference in surface area. In both the treatment groups, there was statistically significant reduction of ulcer surface area at each follow-up compared to baseline [Figure 5]. In a study by Nagaraju A et al.,⁸ significant reduction of ulcer size was observed from the first follow-up onwards by using PRFM and Saha S et al.⁷ also found a significant decrease in size of ulcer by using PRP from the first follow-up onwards.

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Figure 5:

Line diagram comparing the decrease in surface area of ulcer with platelet-rich plasma and platelet-rich fibrin membrane.

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Intragroup change in percentage reduction of surface area was assessed by Friedman test which shows statistically significant difference (p<0.001), compared to baseline, in both the treatment groups. Saha S et al.⁷ found (91.10 + 9.65)% reduction of ulcer size by using PRP with total contactcast at the fifth follow-up compared to baseline with significant percentage reduction from first follow-up onwards. Jagati A et al.⁹ found 93.84% decrease in ulcer size by using PRFM over collagen sheet at the sixth follow-up. In a study by Nagaraju A et al.⁸ and Saha S et al.,⁷ significant reduction of ulcer size was observed from the first follow-up onwards.

Six out of 26 patients (23%) in group A (PRFM with total contact cast) and 3 out of 25 patients (12%) in group B (platelet-rich plasma with total contact cast) had complete healing of the ulcers. In a study by Saha S et al.,⁷ using PRP with total contact cast, 22 (39.29%) patients had complete resolution of ulcer, whereas Sarvajnamurthy S et al.,¹¹ using PRP, found complete resolution in 13 (76%) patients. Jagati A et al.,⁹ using PRFM, found complete healing in seven (46.67%) patients, whereas Nagaraju U et al.⁸ observed complete resolution in all (seven) patients.

Most of the patients in both the groups did not suffer any adverse event (total= 46, 90.2%). Only five patients (9.8%) faced adverse events. In group A, 24 out of 26 patients (92.31%) did not face any adverse event, whereas this figure was 22 out of 25 (88%) in group B. The adverse events in group A (PRFM) were painful foot swelling (due to cellulitis) and nummular dermatitis; adverse events in group B (PRP) were painful foot swelling (due to cellulitis), callosity development and maggot formation. Saha S et al.⁷ reported some other adverse events like pain during PRP injection, iatrogenic ulcer and oedema. But, these were not noted in our study. Nagaraju U et al.⁸ (using PRFM) and Sarvajnamurthy S et al.¹¹ (using PRP) did not find any adverse event.

No statistically significant intergroup difference was found at baseline, third and fifth follow-up DLQI score (Mann–Whitney test: P= 0.316 at baseline, P = 0.125 at third follow-up, P = 0.433 at fifth follow-up). DLQI was found to be significantly improved from baseline to third follow-up and fifth follow-up in both the treatment groups (Friedman test P<0.001). No other study observed a gradual change in DLQI with treatment by PRP or PRFM in leg ulcers.

The major laboratory parameters of the patients (haemoglobin, total leukocyte count, platelet count, total bilirubin and creatinine) were also checked. Most of the patients had values within normal limits. In both the treatment arms, the data were comparable between the groups. There was no statistically significant change in the laboratory parameters with treatment.

On the basis of the requirement of resources, it can be opined that platelet-rich plasma with total contact cast is more a resource and time-consuming procedure than PRFM with total contact cast. The ease of performing the technique (operational feasibility) was more with autologous platelet-rich fibrin matrix than perilesional injectable autologous platelet-rich plasma.

Table 6 shows the comparison between our study and other studies using PRP/PRFM.

Our study was limited by the fact that the time period of active treatment was restricted to 8 weeks due to logistic reasons.

We could follow-up the patient for 1 more month after active treatment but not beyond that.

Conclusion

Both PRP and PRFM were effective in reducing the surface area of the ulcer. The baseline surface area was comparable between the groups. The surface area of the ulcers reduced significantly from the first follow-up onwards in both the groups. There was a significant decline in Dermatology Life Quality Index (DLQI) score in both the treatment groups.Most of the patients in both the groups did not suffer any adverse events. We found that PRFM therapy requires less time, less patients’ blood and materials in comparison with platelet-rich plasma therapy. So, it can be concluded that PRFM may be a more cost-effective and less resource-consuming procedure than platelet-rich plasma therapy. The operational feasibility is more with the PRFM therapy.

So, PRFM is not inferior to platelet-rich plasma therapy with respect to effectiveness, safety and requirement of resources.