hey guys Dr Davin Lim board certified dermatologist today we'll be talking about prp prp stands for
platelet-rich plasma how it's used in medicine what the level of evidence shows how it may or may
not help with acne scarring and i'll also share my experience over many years using prp so what does
it stand for platelet-rich plasma basically prp is derived from the donor the donor is the patient
and what happens is that we extract some blood usually about 50 ml sometimes a little bit more
and the blood is processed with an anticoagulant it's centrifuge and then
it's separated so basically there's three parts of the blood you have the pep which is platelet
poor plasma this isn't used much at all you have the middle which is your rich platelet-rich
plasma with the growth factors in cytokines and then you have your blood cells at the bottom so
what we are interested in is the middle bit the reason why we're actually interested in that the
theory behind prp is that it has growth factors because your platelets very high in growth factors
prostaglandins together with cytokines which basically just add up to make your tissue grow
faster remodel scars and also aids in healing up times so or this is the theory behind it
so prp has been used for many many decades in fact it's we've started using it in
the 1970s however it's gained lots of popularity over the last 15 to 20 years
the main thing about prp um it's it's this there are not many good studies out there that
demonstrate the efficacy of prp in the context of dermatology plastic surgery and aesthetic medicine
the um i guess the best level of evidence of prp is actually believe it not joints so orthopedic
surgeons and sports medicine specialists have been using prp for decades generally speaking uh the
results are pretty good it's more predictable than what we see as dermatologists in people practicing
aesthetic or cosmetic medicine but the orthopedic surgeons have pretty bloody good results
now dermatologists also start using this probably about seven eight years ago as adjunctive
treatment for hair loss once again the level of evidence in the context of androgenic alopecia
or hair loss is much much better compared to the level of evidence for aesthetic as in wound repair
so those two factors i think uh well i think i'm pretty sure when you look at the literature
most people agree the level of evidence is there especially for joints secondly for um hair loss
right now today's topic we'll be talking about prp in the context of
wound repair in particular acne scar revision now when we look at the papers out there it's very
very hard to interpret first of all the numbers are very low so for something to be statistically
significant you've got to have a lot of numbers not only that the trials of or basically the
research behind it has got to be controlled so you need someone to be blinded so first of all
you need subjects to be randomized so randomized to prp and then no prp the other thing is well it
needs to be split face so you can't just go well you know what i'm going to try on this patient
and not do it on that patient because for things like acne scarring there's a lot of variability
so first of all needs to be um like i said it's got to be split up right
and you need to randomize that split you can't select and go well you know this person's got
mild scarring and hence will be on the prb so it has to be randomized secondly split
phase half the face has got to be treated with prp the other half ideally should be treated with
something like a normal saline which is basically salt water the variables need to be controlled
so you need to look at everything from healing up times the volumization changes in other words
the actual outcome when it comes to scarring and also apart from the side effects also patient
satisfaction rate pain scales uh and a whole heap of other stuff so when we look at the level of
evidence it's not crash hot at all um there's a lot a lot a lot of case reports and there's
a lot of small studies so there are three standout studies the first one is done by koreans basically
there were 14 people which were chosen that were randomized and this was basically a split face so
they used co2 laser resurfacing in the context of acne scarring so there's half of it was treated
with prp so the full face was treated with co2 laser resurfacing half of it was treated with prp
six mils the other half treated with normal cell lines so at least we have some kind of control
that studies there was an improvement of acne scars how did they assess it basically they had a
blinded dermatologist no not a blind dermatologist but a blinded dermatologist so the dermatologist
did not know which side was treated with prp and which side was treated with salt water
injections so six mils both sides results of that study showed that the side that had prp after co2
fractional laser resurfacing responded better so not only were the sky improvements better
but also there were less side effects which means there was less swelling there was quicker recovery
there was less crusting there's less pigmentation as well which is basically erythema so all in all
that study was pretty promising but the numbers are very very small so that's only 14 patients
the hard thing to interpret as well is that when we're doing scar revision procedures
most dermatologists most plastic surgeons we always vary our procedures based upon that patient
for example just just quickly for example if someone's got rolling scars we might not need
to actually treat superficially we might actually need to perform for example subcision someone has
more boxcar scarring we're going to use less substitution we're going to use more laser but
if someone's got lighter skin types certainly we use more less in other words higher density
and also more power so you can see there's so many variables that we need to consider
and a lot of these studies they don't consider those variables yeah and that's before we even
talk about variability in scarring but not only that variability in age variability in race
and many other factors as well like for example your health smoking diet the whole lot active
acne not active acne so there's so many variables that we have to keep constant in order to find
what the truth is so that's one study it's not bad but like i said the numbers were only 14. okay the
second study involved 30 patients and they were once again randomized and they were divided into
normal saline so in other words salt water after co2 laser and uh two other arms basically one was
prp that was applied topically in other words not injected just sprinkle on the face and then the
other arm was prp injected intradermally after co2 laser so results of that study basically showed
both intradermal so injected and topical prp fared better than normal saline which is just salt water
once again this was a blinded study assessed by dermatologists once again the number that
was studied very very low so there's only 30 patients involved so you need to actually
interpret that with caution right now the third study is this third study involved
micro needling and involved 35 patients that were allocated to micro needling by itself or
micro needling with prp in that study and that was conducted by two assessors two dermatologists who
were blinded to that and that study showed there was very little in the way of difference between
micro needling and micro needling prp so guys there are many many other studies in this context
a really good summary was done by chris zachary he's one of my i guess one of the people which i
really look um really look up to because chris um you know has got the reputation for a guy that has
no bs um he practices in california and he's a professor of dermatology there so guys uh
there are lots of studies out there there's lots of review articles in this conflicting
data out there some articles show that there's it is improvements some articles even though they're
strong show that there is no improvement so that's where we are we need better design studies in the
future the hard thing about studies is that we need to control a lot of variables when we
talk about acne scarring as mentioned before the variables cannot be controlled especially when you
look at type 1 patients or type 2 patients we're going to approach things differently compared to
someone who's got darker skin type you know skin type threes and three or four now the thing with
the studies however is that the bigger studies are done in places like korea in southeast asia
and also in the middle east there are very very few controlled studies in western medicine now
the problem being with this is that we're treating different ethnicities and we know for example that
ethnic skin types even though they scar worse usually speaking they react differently in the
context of energy devices and also surgery because they can increase more collagen so
does prp have a skewed effect on this population that we've studied most so the bottom line is this
even though there are many studies a lot of reviewers would say that we still need a lot more
we need a lot more studies across a whole range of ethnicities let's come to the other side of
the things my experience for you if you guys have been following me for years you know that in 2016
all the way up to 2018 midway 2018 i use prp on many many patients so you know the old bank robber
mask of when i applied the prp basically i put a mask on that mask stays there for approximately
half an hour obviously the joke at that stage was uh whatever you do don't go into a bank haha
so guys i've done literally hundreds of cases in that in those two and a half years this is my my
take on things first of all why didn't i write a paper on that easy because i could not control the
variables when patients come to see you especially in private practice you're obliged to give in the
best treatment possible and the best treatment's often the best bug treatment so you just don't
pick a laser up and go cool i'm just going to do three passes on this setting you have to vary
your settings you vary your density you vary your joules you vary your different techniques whether
it be the tca or whether it be subcision or the using the co2 and erbium laser etc
so to keep those variables in the private practice is almost impossible um in in you know to do the
right thing you basically treat patients uh in a bespoke manner so your variables are completely
out the door uh so but these are my observations over the last you know over the last uh four or
five years or so as you guys know i was a fan of it initially because i really wanted to believe it
um i've read a lot of the studies i made sure that the for the concentration of prp was in
the order of around 4.5 to 6 x which is six times four point five to six times the concentration the
platelets compared to your normal blood um but at the end of the day i saw very minimal effects
what i saw was that number one patients have a very high satisfaction rate so that
one you can measure that and say hey you know that's going to be a success because
patients really like it now if you're practicing objective medicine which i like to practice
i don't even though they've got a high passion satisfaction rate when i look at them i go wow
have i made a difference have i made a marginal difference have i made a significant difference i
think in the context of scar revision the eventual outcome um and once again i've only done a couple
of hundred cases my gut feeling is that it doesn't work and that's why in in late 2018 i've
stopped and the last time i did prb was probably a couple of weeks ago because someone asked for it
but then you know when i saw the the effects i do believe that it gives you a marginal
improvement uh of healing up times when i mean marginal i think somewhere between 12
to 24 hours so it's not that the prp group of patients when we're actually applying that will
heal up in double the you know half the time right compared to someone who hasn't got prp
we're talking marginal improvements anywhere between 12 hours and the most 24 hours so does
that justify things i think a 12 hour marginal improvement when it comes to you know a blade of
lasers it's pretty small um if that right if that when it came to the outcomes i could not see any
out the differences and i use prp like i said from everywhere from four four and a half x all the way
to six plus x which is basically the concentration i used it intradermally so what i call prp under
i use the prp over which is sprinkling together with a mask and then i also use the under and
over technique which is basically intradermal or cannula injections plus topically as well and you
know when i look back i go wow yeah it i really wanted to believe in it yeah seriously i did
um but if i've stopped it for that reason possibly it may not work as well as what we expect guys
look at the end of the day it's this i think we need to actually do more studies we need to
actually investigate things i think it's going to be very difficult to keep the variables constant
but that's my take on prp and why i don't use it in the context of acne scarring anymore i hope you
liked that video if you've had prp or you know someone's happy happy please comment share and
just tell me your thoughts once again this is very controversial but then like i said it's i'm trying
to keep it real and give you a honest opinion on things so guys please um subscribe if you haven't
subscribed um i do one video i try to do one video every week and i'll see you next week bye for now