PracticeUpdate Dermatology February 2019

EXPERT OPINION 25

Platelet-RichPlasma for the Treatment of Diabetic Foot Ulcers By Eliot N. Mostow MD, MPH D iabetic foot ulcers are the leading cause of leg amputations worldwide, and there are a number of studies that demonstrate the central role of impaired granulation tissue formation in these chronic ulcers. Thus, it seems reasonable that platelet-rich plasma (PRP) with multiple cytokines/growth factors might turn these stalled ulcers into a more rapidly healing phase, thus closing the ulcer sooner and reducing the need for ultimate amputations. A number of studies have attempted to demonstrate this benefit. This nicely performed meta-analysis published in a quality wound care journal demon- strates improvement in healing, albeit moderate, as measured by time to complete wound healing and volume reduction. 1 That being said, PRP treat- ment did not improve the probability of wound complications or recurrences, although it did seem to reduce the rate of adverse events. Allowing for the fact that these are difficult studies to perform for multiple reasons, the authors correctly note that there are “serious methodologic flaws” in many of the previous studies. I’ve been lucky enough to be involved in the care of patients with chronic wounds for over 20 years. It would be very nice if a new treatment provided miraculous results. So far, nothing has really jumped out to catch my atten- tion as a true game changer. That being said, work with growth factors and other biologic dressings have certainly made a difference in wounds that are not responding to standard conventional therapy. In the world of med- ical care, especially wound care, there is certainly an art to optimizing the care for individual patients. There are almost always comorbidities and social and psychosocial factors that play into treatment options and compliance. Thus, it is important for physicians to choose treatments that are best for the patient in terms of their ability to afford a given treatment and comply with the regimen that’s been prescribed. PRP has never been my “go to” preferred treatment for stalled wounds, but that doesn’t mean it is not appropriate in certain cases. I have tended to favor collagen-based products or live cell products when the wound is not responding as I think it should with conventional therapy (moist wound heal- ing, infection control, offloading, and debridement are keys for diabetic foot ulcers). I always like to remind people that a biopsy can also be important to make sure you’re not dealing with a skin cancer or treatable infectious process. It’s also critical to take good photographs to demonstrate whether a wound is improving or not. In the end, especially with respect to diabetic foot ulcers, offloading and debridement are the key components to any reg- imen designed to promote ulcer healing. Without specific attention to the simple details, more people will suffer amputations than necessary, no mat- ter what “advanced” dressing or procedure is used. I would be remiss if I did not encourage more physicians to get involved in the care of patients with chronic wounds. This is a significant problem that really can benefit from multidisciplinary care, including dermatologists, plastic surgeons, vascular surgeons, and infectious disease and primary care physicians. Sending your patient to a specific wound clinic can offer definite advantages in terms of getting the right people together to do proper offloading and documentation, and also offer advanced wound treatments. That being said, we all need to advocate for our patients and make sure that the clinics they attend are staffed with people who are taking a patient- centered approach to clinical care. Reference 1. T Del Pino-Sedeño, MM Trujillo-Martín, I Andia, et al. Wound Repair Regen 2018 Dec 21;[EPub Ahead of Print]. www.practiceupdate.com/c/77878

(“What we have here is a failure to communicate”) even in our written reports. Dermatologists and dermatopa- thologists need to understand each other. After reading Willardson’s article, I wrote to my colleagues to make sure that they precisely understood what I mean by “the tumor appears to be completely excised on the sections studied” when they read my report – that alone will optimize patient outcomes. Communication is also a two-way street. I would find it most helpful to know the intent of the biopsy. If it is “rule out BCC,” I have to assume it is for diagnostic reasons only. Alter- natively, if the specimenwas submitted as “BCC– small lesion – margins clear?” the dynamic changes. When it comes to margins of skin cancer, we have to make sure there is no margin for error in the interpretation of our reports. Point to Remember: On routine biopsies of basal cell carcinomas, you cannot rely on comments about the involvement of the margin, or lack thereof. Make sure that you and your dermatopathologist understand each other for optimal patient care. Disclaimer : First published on Dr. Warren Heymann’s Der- matology Insights and Inquiries website on July 30, 2018. Republished with permission. References 1. Willardson HB, Lombardo J, Raines M, et al. Predictive value of basal cell carcinoma biopsies with negative margin: a retrospective cohort study. J Am Acad Dermatol 2018;79(1):42-46. 2. Schnelbelen AM, Gardner JM, Shalin SC. Margin status in shave biopsies of nonmelanoma skin cancers: Is it worth reporting? Arch Pathol Lab Med 2016;140(7):678-681. 3. Cameron MC, Lee E, Hibler B, et al. Basal cell carcinoma. Part I. J Am Acad Dermatol 2018 May 18. doi: 10.1016/j. jaad.2018.03.060. [Epub ahead of print.] 4. Korbi JD, Wood BA, Harvey NT. 'Why don’t they ever call?' Expectations of clinicians and pathologists regarding the communication of critical diagnoses in dermatopathology. Pathology 2018;50(3):305-312. www.practiceupdate.com/c/72150

VOL. 3 • NO. 1 • 2019