Original Contribution

Journal of Cosmetic Dermatology, 15, 108--116

The effect of platelet-rich plasma on the outcome of short-term

narrowband–ultraviolet B phototherapy in the treatment of vitiligo:
a pilot study
Zeinab A Ibrahim, MD,1 Amal A El-Ashmawy, MD,1 Rania A El-Tatawy, MD,1
& Fersan A Sallam, MD2
1
Department of Dermatology & Venereology, Faculty of Medicine, Tanta University, Tanta, Egypt
2
Department of Pathology, Faculty of Medicine, Tanta University, Tanta, Egypt

Summary Background Narrowband – ultraviolet B (NB-UVB) is an emerging, effective, and safe

therapy for vitiligo, but the treatment course often requires a long duration of time
which may carry a potential risk for various side effects and patients’ noncompliance.
Objective To explore the effect of platelet-rich plasma (PRP) injection on the outcome
of short-term NB-UVB therapy for the patients with stable vitiligo.
Patients and methods The study included 60 stable vitiligo patients with overall
symmetrical lesions. For each patient, the left side of the body was treated with NB-
UVB alone (control side) while the right side was treated with NB-UVB therapy in
addition to intradermal injection of PRP, every 2 weeks for 4 months.
Results There was statistically highly significant improvement in the repigmentation
in the combination group(PRP plus NB-UVB) compared with NB-UVB group.
Conclusion Intradermal PRP injection in combination with NB-UVB could be
considered as a simple, safe, tolerable, and cheap technique for treatment of vitiligo.
It shortens the duration of NB-UVB therapy and is expected to increase patient
compliance. Longer follow-up is needed.
Keywords: narrow-band UVB, platelet-rich plasma, vitiligo

find this long duration of therapy inconvenient due to

Introduction
The NB-UVB phototherapy is considered to be a very
important modality in vitiligo treatment since its first
use in 1997.1 It was proved to be of higher efficacy,
better tolerated, and superior to the other lines of treat-
ment.2 Nevertheless, it is an office-based treatment that
may require more than 1 year for its completion.
Although success in many cases, some patients may
Correspondence: Amal A El-Ashmawy, Department of Dermatology &
Venereology, Faculty of Medicine, Tanta University, El- Bahr street, 7942
Tanta, Egypt.
E-mail: Elashmawy2013@yahoo.com
Accepted for publication October 16, 2015
social and financial reasons.3
Platelet-rich plasma (PRP) is an autologous prepara-
tion of platelets in concentrated plasma. Various
growth factors, including platelet-derived growth fac-
tor, transforming growth factor, vascular endothelial
growth factor, and insulin-like growth factor, are
secreted from a-granules of concentrated platelets acti-
vated by aggregation inducers.4,5 These factors are
known to regulate many processes including cell
migration, attachment, proliferation, differentiation,
and promoting extra cellular matrix accumulation by
binding to specific cell-surface receptors.6,7 Due to the
presence of high concentration of these growth factors,
PRP has been used in wide variety of surgical proce-

108 © 2015 Wiley Periodicals, Inc.

 PRP plus NB-UVB in vitiligo . Z A Ibrahim et al.

dures and clinical treatment. 8 PRP has attracted Platelet-rich plasma separation method10
attention in the field of dermatology specifically in the
To create PRP, 10 to 20 cc of venous blood had been
esthetic field for skin rejuvenation, acne scars, and hair
collected from the anticubital vein under complete
loss, it is considered an excellent safety profile with
aseptic conditions.10 The whole blood sample was col-
relatively low cost.5
lected in tubes containing sodium citrate (10:1) as an
The aim of the study was to explore the effect of
anticoagulant (to bind calcium and prevents the initi-
PRP injection, on the outcome of 4 months of NB-UVB
ation of the clotting cascade by preventing the con-
phototherapy as a short-term technique for treating
version of prothrombin to thrombin). Then the
nonsegmental stable vitiligo patients.
citrated whole blood was subjected to two centrifuga-
tion steps. The initial centrifugation was done (“soft”
Study design spin) at 3000 rpm for 7 min to separate the plasma
and platelets from the red and white cells. The result-
The study was a prospective left–right comparative
ing plasma supernatant, which contained the sus-
controlled study. A pilot study.
pended platelets (and may contain a portion of the
white cell “buffy coat”) was harvested to a second
Patients and methods centrifugation step (“hard” spin) at 4000 rpm for
5 min, leading to separation of the plasma into 2 por-
A total of 60 Egyptian patients were enrolled in the
tions:- platelet-poor plasma (PPP) and PRP. Typically,
study. They were collected from the Outpatient Clinic
the lower 1–2 cc of the plasma (10% of the initial
of Dermatology and Venereology Department, Tanta
volume of autologous blood), was yielded as PRP con-
University Hospitals, Egypt, during the period from
centrate after centrifugation. Platelets in this final
March 2014 to March 2015 after obtaining the
product were estimated to be ≥4 times more concen-
approval of the research ethics committee of the Tanta
trated than the whole blood. Then PRP was activated
University Hospitals (code no. 7520/03/14). They had
by adding calcium chloride at ratio of 10:1 (0.1 cc of
overall symmetrical stable lesions [absence of new
CaCl2 to each 1 cm of PRP) immediately before the
areas of depigmentation or enlargement of the preexist-
injection. It was injected intradermally using insulin
ing lesions for 12 months and absence of Koebner
syringe in the lesion, 0.1 cc of PRP was injected per
phenomena during the same period]. Patients who
point with a space of 2 cm between different points of
were known to have a good or rapid response to con-
injections. This procedure was repeated every 2 weeks
ventional modalities were excluded from the study.
for every patient for maximum 4 months (8 sessions).
Pregnant or lactating females and young patients
The patients were followed up for 3 months after the
below18 years were also excluded from this study. For
last session.
each patient, the left side of the body was treated with
NB-UVB alone (control side) while the right side was
treated with NB-UVB therapy in addition to intrader- Evaluation of the treatment
mal injection of PRP every 2 weeks. Patients were
Clinical assessment
photographed at the first visit, in the middle and at
The patients were examined in the first visit and were
the end of therapy. Each patient signed a written
reviewed weekly for the progress of therapy and the
consent form to be included in the study and to be
presence of any side effects. Evaluation of pigmentation
photographed.
was done by two independent dermatologists. The
repigmentation response was expressed qualitatively
The NB-UVB therapy as: excellent: >75 to 100%, good: >50% to 75%, mod-
erate: >25% to 50% and mild: <25%.11 Quantitative
All patients received NB-UVB sessions twice per week
evaluation of the response was also performed in a
for a maximum of 4 months or when complete repig-
numerical percentage for precise statistical evaluation.
mentation was achieved. The NB-UVB source was
eight NB fluorescent tubes (Philips TL 100, Hamburg,
Safety assessment
Germany) with a spectrum of 310–315 nm and a
The patients were informed to report any complica-
maximum wave length of 311 nm installed in a Wald-
tions as; erythema, pain, ulceration, burning sensation,
mann UV-100 unit. The initial dose of UVB was
ecchymosis, infection, postinflammatory hyperpigmen-
0.33 J/cm2, and increased by 20% every session till
tation, or any allergic manifestations.
the minimal erythema dose was achieved.9

© 2015 Wiley Periodicals, Inc. 109

PRP plus NB-UVB in vitiligo . Z A Ibrahim et al.
Follow-up assessment
The patients were followed-up monthly for 3 months
after the end of the treatment sessions to detect any
recurrence, complications or worsening of the lesions.
Histopathological examination
Three-millimeter punch biopsy specimen was taken
from the lesional sites before treatment, and another
biopsy was taken from the same site after the end of
treatment sessions from each side of 10 patients. The
biopsy specimens were stained by hematoxylin and
eosin (H&E) and special stains using S100 and
HMB45, to study histopathological changes in the end
of the treatment sessions.
Statistical analysis
The data were collected, tabulated and statistically
analyzed using SPSS software statistical computer
package version 12. For quantitative data, the mean
and standard deviation were calculated. The difference
between two means was statistically analyzed using
the Student’s t-test. P-value £ 0.05 was considered
statistically significant.
Results
This study included 60 patients with localized stable
nonsegmental, symmetrical vitiligo, 26 males and 34
females. Their ages ranged from 18 to 35 years old
with a mean of 28  5.65. The age of onset of lesions
ranged from 1 to 10 years with a mean of 5.9  6.2.
42 patients had skin phototypes IV and 18 patients
had skin phototypes III. The vitiligo lesions are dis-
tributed in the trunk in 15 patients, 21 in the face, 12
in the acral parts and 12 in the extremities.
Clinical assessment
In the PRP side, the pigmentation started after the
second session in 15/60 (25%) and after the third
session in 26/60 (43.3%) of patients. It appeared as
dots of hyperpigmentation at the sites of injections,
and then progressed subsequently to make full
patches of repigmentation. The pattern of repigmenta-
tion was follicular in 68.8% of patients, while 22.2%
showed diffuse pigmentation. In the control side, pig-
mentation was detected in 6/60 (10%) patients at the
third session.
In the PRP group, 33 patients (55%) had excellent
response, 12 patients (20%) had good response, 9
(15%) patients had moderate response, and 6(10%)
110
patients had mild response, while in control group, no
patients had excellent or good response after 4 months
of sessions, 4(6.7%) patients had moderate response,
45(75%) patients had mild response, and 11(18.3) had
no response.
The qualitative response was significantly increased
in the PRP side than the control side (Figs 1 and 2,
Table 1). The quantitative response was significantly
higher in the PRP side than in control side in all body
parts (P < 0.001) (Table 2). There was no significant
correlation between the repigmentation, skin photo-
type, age, or sex of the patients.
Regarding the side effects; there were no complications
in 27 patients (45%), the remaining 33 patients (55%)
reported some side effects as; pain during injection in
30 patients (50%), ecchymosis in 9 patients (15%).
Follow up period assessment
After 3 months of follow-up, the PRP side continued
improving and no relapses was reported while in the
control side, depigmentation restarted again in 50% of
the patients. No Koebner phenomenon could be
detected throughout the study from repeated injec-
tions.
Histopathological evaluation
Before treatment; section stained with H &E revealed
complete absence of melanin pigmentation (Fig. 3a).
After the end of treatment with PRP plus NB-UVB; the
H&E-stained section revealed expression of prominent
melanin pigmentation (Fig. 3b) while there was weak
melanin pigmentation after NB-UVB (control side)
(Fig. 3c).
Regarding the special stains; before treatment there
was negative expression for both S100 (Fig. 4a) and
HMB45 (Fig. 5a) in vitiligo lesion. After treatment with
PRP plus NB-UVB, there was marked expression for
both S100 (Fig. 4b) and HMB45 (Fig. 5b), while after
treatment with NB-UVB alone there was mild to mod-
erate expression for both S100 (Fig. 4c) and HMB45
(Fig. 5c).
Discussion
In the PRP group, 55% of the patients achieved excel-
lent repigmentation and 20% achieved good repigmen-
tation in a 4-month duration which was considered as
a remarkable outcome in such a short duration com-
pared to NB-UVB side, there were neither excellent nor
good responses.
© 2015 Wiley Periodicals, Inc.
 PRP plus NB-UVB in vitiligo . Z A Ibrahim et al.

(a) (b)

(c) (d)

Figure 1 Female patient with vitiligo on: (a) right thigh before treatment, (b) 4 months after PRP injection and NB-UVB with excellent
improvement. (c) left thigh before treatment, (d) 4 months after treatment with NB-UVB with mild improvement.

Westerhof and Neiuweboer–Krobotova in 1997,1
analyzed the outcome of NB-UVB therapy in vitiligo;
they found that after 3 months only 8% of patients
showed a marked response compared to 63% after
1 year. The prolonged duration of NB-UVB therapy is
the main reason for noncompliance, distance to be
traveled and monetary, and time loss in attending the
hospital at least twice a week for prolonged time were
cited as the second common cause for attrition. 12 This
clearly increases the need for combined therapy with
NB-UVB to shorten the duration.
This study revealed statistically highly significant dif-
ference in the degree of improvement in comparing
PRP group with the control group (P < 0.001). So, the
use of intradermal PRP could shorten the duration of
UVB exposure (so decreases the cumulative dose) and
improve the outcome repigmentation which may be
more convenient for many patients for health, financial
and social reasons.
There was only one study about the role of PRP in
vitiligo. It was done in 2011, by Lim et al. 13 They
treated 20 patients with vitiligo by intradermal injec-
tion of PRP weekly for 10 weeks and they suggested
that PRP was not effective in the treatment of vitiligo.
In this study with regard to body site, vitiligo of the
face, trunk and extremities showed the best results.

© 2015 Wiley Periodicals, Inc. 111

PRP plus NB-UVB in vitiligo . Z A Ibrahim et al.

Figure 2 Female patient with vitiligo on: (a) right leg before treatment, (b) 4 months after PRP injection and NB-UVB phototherapy
with excellent response, (c) left leg before treatment, (d) 4 months after NB-UVB phototherapy with mild response.

Table 1 Comparison between degree of improvement in both Table 2 The quantitative response to therapy in different body
groups parts in both treated sides

PRP group Control group Range Mean  SD t-test P value

(n = 60) (n = 60)
Degree of Extremities
improvement No. % No. % PRP 45.0–98.0 78.50  17.95 11.040 0.001*
Control 0.0–40.0 13.25  9.86
No 0 0 11 18.3 Trunk
Mild 6 10 45 75 PRP 50.0–97.0 71.80  18.72 9.634 0.001*
Moderate 9 15 4 6.7 Control 0.0–50.0 15.0  13.09
Good 12 20 0 0 Facial
Excellent 33 55 0 0 PRP 60.0–95.0 75.71  26.68 10.753 0.001*
v2 (MCp) 26.549* (<0.001*) Control 0.0–20.0 11.00  8.11
Acral
v2, Value for chi square. PRP 0.0–25.0 16.75  10.76 4.993 0.001*
Control 0.0–10.0 4.25  1.36
MC, Monte Carlo test.
*
Statistically significant at P ≤ 0.05. *
Statistically highly significant at P ≤ 0.001.

The acral parts, however, showed poor response and and PUVA occurred on the face and neck. The acral
hardly repigmented, but were statistically significant parts and areas over bony prominence were difficult to
than the control group and this coincides with the pre- repigment because of the lower hair follicle density,
vious studies. 14,15 Moreover, the best results of UVB which are the reservoir of melanocytes.16,17

112 © 2015 Wiley Periodicals, Inc.


Figure 3 Vitiligo section stained by H&E: (a) before treatment
showed absence of melanin pigmentation (H&E 200), (b) after
treatment by PRP plus NB-UVB revealed prominent melanin pig-
mentation (H&E × 100), (c) after treatment by NB-UVB alone
revealed weak melanin expression (H&E × 200).
© 2015 Wiley Periodicals, Inc.
PRP plus NB-UVB in vitiligo . Z A Ibrahim et al.
Figure 4 Vitiligo section stained by S100: (a) before treatment
showed negative expression for S100 (PAP × 50), (b) after treat-
ment by PRP plus NB-UVB showed marked expression of S100
(PAP × 200), (c) after treatment by NB-UVB showed moderate
expression of S100 with melanin incontinence (PAP × 100).
The reported side effects in the PRP group were few
and minor and all patients tolerated the procedure
well. Pain occurred in 50% of the patients which was
113
PRP plus NB-UVB in vitiligo . Z A Ibrahim et al.
Figure 5 Vitiligo section stained by HMB45: (a) before treatment
showed mild expression of HMB45 (PAP × 200), (b) after treat-
ment by PRP plus NB-UVB revealed marked expression of
HMB45 (PAP × 200), (c) after treatment by NB-UVB revealed
moderate expression of HMB45 (PAP × 200).
mild tolerable pain and disappeared within few min-
utes after the end of the injection. Ecchymosis at the
site of injection occurred in 15%. Hence intradermal
injection of PRP is considered costly effective and safe
114
therapy which does not require a costly device or
equipped room.
With interest this combination could be applied not
only for the localized areas of vitiligo but also suitable
for relatively large areas of vitiligo unlike minigraft or
melanocytes transplantation. Also, it could be also
used in any site unlike surgical treatment which could
not be used in some areas like eye lids, genitalia, fin-
gers, and cutaneous folds.
The exact mechanism of action of PRP in vitiligo is
still unknown. It was reported that not only melano-
cytes but also keratinocytes and fibroblasts are
involved in the pathogenesis in vitiligo in some ways.4
Deficiency in unidentified growth factors as fibroblast
growth factor and keratinocyte growth factor may be
responsible for weakening of melanocytes attachment
and lead to their detachment that cause transepider-
mal elimination and chronic melanocytorrhagy.18 The
beneficial effect of PRP in vitiligo could be suggested
through these growth factors which stimulate ker-
atinocytes and fibroblasts proliferation with subsequent
improvement of their interaction with melanocytes
leading to the stabilization of melanocytes. It was also
found that PRP treatment induced accelerated prolifer-
ation and migration of fibroblasts through upregula-
tion of cyclin E and CDK4, which is important in cell
migration and proliferation.19
Moreover, many studies supporting the role of PRP
through its growth factors in skin rejuvenation
through stimulative effects on the proliferation of colla-
gen, fibroblasts, and keratinocytes.10,20–23 The growth
factors (platelets derived growth factor and transform-
ing growth factor-beta) bind to the transmembrane
receptors of target cells in the repair site (e.g., mes-
enchymal stem cells, osteoblasts, fibroblasts, endothe-
lial cells, and epidermal cells) activating intracellular
signal proteins leading to the expression of gene
sequence which result in either cellular proliferation,
new matrix formation, new collagen formation, or epi-
dermal cell proliferation.24,25
Angiogenic factors, including vascular endothelial
growth factor and fibroblast growth factor-2, are con-
sidered to enhance early angiogenesis and revascular-
ization.26 Other growth factors and secretory proteins
act by attracting undifferentiated stem cells to the newly
formed matrix triggering their proliferation and differen-
tiation serving the healing cascade and tissue regenera-
tion.27 Stem cells may contribute to other cells that
make up the skin such as keratinocytes and fibroblasts.
Keratinocyte communication with mesenchymal stem
cells in the dermis is essential in maintaining the
integumentary structure of the skin.28Whether the
© 2015 Wiley Periodicals, Inc.

effect of PRP in repigmentation is due to stimulating
proliferation and differentiation of mesenchymal stem
cell to melanocytes, still need further studies.
In vitro studies demonstrated an increased production
of pro-inflammatory cytokines IL-6 and IL-8 by mono-
cytes of patients with active vitiligo. These could not
only play an important role in effector cell migration
and effector target attachment but also cause B-cell acti-
vation. 29 Moreover, T helper cells secrete IL-17 which
synergizes with these local inflammatory mediators,
causing further inhibition of melanocyte proliferation.30
Huang et al.31suggested the apoptosis hypothesis in viti-
ligo which proposes that cytokines such IL-1, IFN-c or
TNF-a, released by lymphocytes, keratinocytes, and mel-
anocytes can initiate apoptosis.32Growth factors of PRP
suppress cytokine release, limit inflammation and limit
apoptosis of melanocytes. 33
Based on the collection of indirect evidence, it could
be postulated that PRP therapy in vitiligo lead to repig-
mentation through these possible mechanisms, stimu-
lation of proliferation, and interaction of both
keratinocyte and fibroblast with melanocytes, attrac-
tion and stimulation of undifferentiated stem cell and
anti-inflammatory effect of PRP which limits the
release of cytokines and subsequently limit apoptosis of
melanocytes. PRP improve the environment for mela-
nocytes to grow and be attached well to keratinocytes
while the UVB stimulate melanogenesis and suppress
the immune process; all the mechanisms act synergisti-
cally to improve the results.
Finally from this study, it could be concluded that;
autologous intradermal PRP injection could be consid-
ered as an effective alternative therapy in treatment
of vitiligo, safe because it is autologous, has minimal
side effects and is free from concerns over transmissi-
ble diseases. PRP requires no special considerations
regarding antibody formation and leading to better
acceptance by patients. It has the advantage of being
costly effective which gives good to excellent results
in most patients. Furthermore, it could be suggested
that combination of PRP with NB-UVB, augments its
effect, improves the outcome repigmentation because
PRP stabilizes melanocytes and NB-UVB stimulates its
proliferation which in turn leads to a better response
in a short duration, but there were many limiting fac-
tors in this study such as it is a nonrandomized
study, small number of the patients, and we could
not estimate the exact number of platletes. Further
controlled clinical trials are needed to confirm this
preliminary observation. The follow-up period is
needed to be more longer up to 1 year.
© 2015 Wiley Periodicals, Inc.
PRP plus NB-UVB in vitiligo . Z A Ibrahim et al.
Recommendations
Further controlled and randomized studies are needed
to validate PRP efficacy and safety in a large cohort of
vitiligo patients alone and with other lines of treat-
ment. Further insight into the mechanism of action of
PRP therapy is strongly encouraged. In vitro studies
are required to assess the direct and indirect effect of
PRP on melanocyte microenvironment.
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