Studies to ascertain the safety and effectiveness of autologous platelet-rich plasma (PRP) in pediatric populations and obtain evidence to optimize protocols of care for persons with spinal dysraphism who develop neuropathic wounds are needed. A wound is defined as a disruption of the normal anatomical structure and function of the skin, and wounds that fail to proceed through an orderly and timely process to anatomical and functional integrity are considered to be chronic wounds.1 A chronic wound is a common and challenging problem in rehabilitation settings. A neuropathic ulcer, a common cause of a chronic nonhealing wound, results because of repetitive trauma to a hyposensitive distal extremity, usually over a weight-bearing bony prominence.2 Diabetes mellitus and peripheral neuropathy are common causes of neuropathic ulcer in adults, whereas spinal dysraphism is a commonly seen condition associated with neuropathic ulcers in the pediatric population.2–4 Factors such as lack of parental care, cognitive impairment, associated deformity and adapted walking pattern, and incontinence contribute to frequent ulcerations or skin breakdown in children with spinal dysraphism.3,4 Nutritional support, local wound care, relief from repetitive stress and shear, addressing the etiology or systemic cause, and sometimes surgical intervention are the conventional/traditional treatments in such cases.2,3
Wound healing is a complex, dynamic process involving interactions of cytokines, growth factors, blood, and extracellular matrix.1,5 Various local and systemic factors play an important role in the chronicity of a nonhealing wound. Repetitive stress and shear, chronic hypoxia, reperfusion injury, nutritional deficit, and growth factor abnormalities are described in literature as factors leading to chronic, nonhealing wounds.2 A wide variety of advanced topical wound treatment strategies, such as hyperbaric oxygen, negative pressure wound therapy, PRP, tissue engineering, and stem cell treatment, are available.2,6
Various in vivo and in vitro studies have documented the efficacy of autologous PRP in the production of stimulatory factors, such as transforming growth factor-beta, basic fibroblast growth factor, platelet-derived growth factor, epidermal growth factor, vascular growth factor, and connective tissue growth factor, which modulate cellular proliferation, angiogenesis, and collagen and fibroblastic production.6–9 PRP can also create a local nonspecific immune response and has been shown to exhibit antimicrobial effects against Staphylocoocus aureus and Pseudomonas aeruginosa in some in vitro studies.7,9,10 Additionally, in chronic wounds, PRP can inhibit cytokine release from macrophages, improving tissue healing and regeneration, promoting new capillary growth, and accelerating epithelization.7
Treatment with PRP leads to wound healing via a continuum of events that are mutually influenced in terms of promotion and inhibition of their progression. A systematic review and meta-analysis has shown complete to partial wound healing response with PRP therapy in various skin conditions such as post-traumatic wounds, surgical wounds, neuropathic wounds, and venous ulcers.11 PRP has also been used effectively in the treatment of pressure ulcers in a prospective study involving 25 patients with spinal cord injury, with 96% of patients showing improvement by the end of the fifth week of treatment.12
Contraindications for the use of PRP are the presence of active infection and an inability to comply with postprocedure guidelines (eg, scheduled follow-up, weight-bearing instructions, care of dressed limb/segment). Some studies have indicated that hematologic disorders, immunosuppressive states, and coagulopathy are exclusion criteria, but these contraindications are relative and physician-dependent.13 Because of young cells and strong healing potential, use of PRP is less well-known in the pediatric population. A review of current clinical studies revealed ongoing use of PRP in pediatric conditions such as cleft lip, cleft palate, and closure of recurrent cleft palate fistulas.6 Use of autologous PRP is being considered in various clinical settings involving wound care as well as musculoskeletal and surgical conditions,6,7 but this needs more and stronger evidence regarding formulations, techniques, and indications.2,6,14 To the authors’ knowledge, there is no literature showing the use of PRP in neuropathic ulcer in patients with spinal dysraphism. Research is underway for use of PRP in various age groups and in various conditions, but there are no known age-based contraindications to its use topically. The current case report documents the response of a chronic, nonhealing neuropathic ulcer over the dorsum of the left foot to autologous PRP and the use of a plaster of paris cast in a child with spinal dysraphism.