Best evidence summary for platelet-rich plasma treatment of chronic wounds

Abstract

Objective

To summarize the best evidence for platelet-rich plasma therapy in chronic wounds, providing an evidence-based foundation for standardizing its clinical practice.

Methods

Guided by the “6S” evidence pyramid model, we systematically searched 12 databases including Cochrane Library and Pubmed, 9 guideline websites including Guidelines International Network (GIN) and National Institute for Health and Clinical Excellence (NICE), and 10 professional websites including World Union of Wound Healing Societies (WUWHS), for relevant evidence from the establishment of the database to May 1, 2025. Two researchers independently conducted quality assessment, evidence extraction, and integration of the included literature.

Results

A total of 17 articles were included, comprising 3 guidelines, 5 expert consensus statements, and 9 systematic reviews. The evidence was categorized into six key treatment domains: application principles, indications and contraindications, pre-treatment preparations, treatment protocols, efficacy monitoring, and management strategies. 27 individual recommendations were derived from these categories.

Conclusion

Platelet-rich plasma therapy can be used as an adjunctive treatment for the management of chronic wounds. Clinicians and wound care specialists should thoroughly assess the applicability and timing of platelet-rich plasma, considering the specific clinical context, and combine it with the patient's physical condition and preferences for clinical application, promoting chronic wound healing and reducing the global disease burden of chronic wounds.

Highlights

• •A systematic summary of global evidence for platelet-rich plasma in chronic wounds.
• •Twenty-seven evidence items across six domains guide PRP clinical practice.
• •PRP efficacy is wound-type specific, with strong evidence for venous ulcers.

Abbreviations

PRP

Platelet-rich plasma

PDGF

Platelet-derived growth factor

TGF-β

Transforming growth factor-β

VEGF

Vascular endothelial growth factor

EGF

Epidermal growth factor

JBI

Joanna Briggs Institute

GIN

Guidelines International Network

NICE

The National Institute for Health and Care Excellence

RNAO

Registered Nurses' Association of Ontario

SIGN

Scottish Intercollegiate Guidelines Network

NZGG

New Zealand Guidelines Group

NHMRC

National Health and Medical Research Council of Australia

NGC

National Guideline Clearinghouse

AMA

American Medical Association

CNKI

China National Knowledge Infrastructure

WUWHS

World Union of Wound Healing Societies

AAWC

Association for the Advancement of Wound Care

IWII

International Wound Infection Institute

AWMA

Australian Wound Management Association

WCET

The World Council of Enterostomal Therapists

WOCN

Wound, Ostomy, and Continence Nurses Society

ASCRS

American Society of Colon and Rectal Surgeons

UOAA

United Ostomy Associations of America

NSWOCC

Nurses Specialized in Wound, Ostomy, and Continence Canada

WHO ICTRP

World Health Organization International Clinical Trials Registry Platform

ANZCTR

Australia New Zealand Clinical Trials Registry

ChiCTR

China Clinical Trial Registration Center

AGREE II

Appraisal of Guidelines for Research and Evaluation

1. Introduction

Chronic wounds are defined as skin injuries that fail to restore anatomical integrity and physiological function after ≥4 weeks of standardized treatment [1]. Common types include diabetic foot ulcers, pressure injuries, venous ulcers, and arterial ulcers [2]. With accelerating global population aging and increased prevalence of metabolic diseases such as diabetes and obesity, the incidence of chronic wounds continues to rise. An estimated 1 %–2 % of the global population suffers from non-healing chronic wounds [3]. Characterized by prolonged treatment duration, high costs, persistent pain, mobility limitations, and reduced self-care capacity, these wounds severely compromise patients’ physical and psychological well-being and quality of life [2,4], while imposing substantial burdens on healthcare resources. Severe cases may lead to infection, sepsis, and even death. According to international medical economic research, the U.S. healthcare system spends over $25 billion annually on this issue, affecting 6.5 million patients [5]. The National Health Service in the UK saw wound care costs rise by 67 % from 2012/2013 to 2017/2018, reaching an annual expenditure of £830 million [6]. In European countries, wound management expenses typically account for 2 %–4 % of total health expenditure [7].

Achieving safe and effective management of chronic wounds while reducing their disease burden has become a shared challenge for global healthcare systems. Platelet-rich plasma (PRP) has attracted widespread attention due to its unique biological characteristics. PRP is a high-concentration platelet suspension extracted and enriched from the patient's own blood or from donated blood [8,9]. PRP stimulates tissue repair and accelerates the healing process of chronic wounds by releasing various bioactive factors stored in platelets, including platelet-derived growth factor (PDGF), transforming growth factor-β (TGF-β), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), and adhesion molecules [10,11]. These factors work together to regulate the inflammatory response, promote angiogenesis, and enhance extracellular matrix reconstruction [10,11]. Clinical data have shown that PRP can significantly improve the complete healing rate of chronic wounds, shorten healing time, and reduce the incidence of adverse events [[12], [13], [14]]. As an economical and readily accessible treatment, PRP leverages the patient's biological resources to promote healing and tissue regeneration. Compared to conventional therapies, PRP demonstrates significantly shorter hospital stays and lower treatment costs [15].

Currently, there is a variety of evidence regarding the application of PRP therapy in chronic wounds, with different types of studies focusing on different aspects. Some expert consensus specifically addresses the preparation of PRP [16], while some systematic reviews focus on the effectiveness of PRP therapy [12]. However, the evidence is fragmented and inconsistent, making it difficult for clinical decision-makers to obtain and implement effective information in practice. Moreover, most related studies do not summarize evidence levels and recommendation strengths, which hinders further clinical translation and scientific application of the evidence. Against this backdrop, it is especially important to use scientific methods to integrate, evaluate, and categorize the existing evidence. Best evidence summaries, as a core component of evidence-based nursing, aim to synthesize the highest quality and most relevant research findings to extract clear and actionable recommendations, providing direct support for clinical decision-making [17]. Therefore, this study will systematically retrieve global evidence on PRP treatment for chronic wounds, rigorously grade the evidence quality based on the Joanna Briggs Institute (JBI) evidence pre-grading and evidence recommendation grading system, and summarize the best evidence for PRP therapy in chronic wounds, aiming to provide evidence-based support for clinical practice standard management.

2. Methods

This study was conducted as a best evidence summary and was officially registered with the Evidence-Based Nursing Center at Fudan University (Registration Number: ES20257632). A streamlined approach was deemed appropriate for this clinical question for two key reasons: first, a substantial body of high-level evidence (including guidelines and systematic reviews) already exists on the use of PRP for chronic wounds [[12], [13], [14], [15], [16]]; and second, there is a pressing need in clinical practice for consolidated, actionable recommendations to guide care. This methodology allows for the efficient synthesis of this existing evidence to meet that need directly.

Based on the methodology of the JBI Evidence-Based Medicine Center in Australia, the Evidence-Based Nursing Center at Fudan University has developed guidelines for evidence summary reporting [18]. These guidelines cover six aspects: problem formulation, literature search, literature selection, literature evaluation, evidence synthesis and classification, and the development of practice recommendations. This study follows the evidence summary reporting standards established by the Evidence-Based Nursing Center at Fudan University [18]. This study is a secondary analysis of the existing literature and is considered exempt from ethical review.

2.1. Problem establishment

The evidence-based practice question is constructed based on the PIPOST model [19], with the specific content as follows: First P (target population):patients with chronic wounds who are over 18 years of age. I (intervention): platelet-Rich Plasma. Second P (professional): healthcare professionals providing treatment and care for patients with chronic wounds. O (outcome): wound-related outcomes (e.g., healing rate, healing time, amputation rate) and self-reported outcomes (e.g., pain, quality of life, satisfaction). S (setting): wound care centers, wards, outpatient departments, and other relevant units in healthcare institutions. T (type of evidence): guidelines, expert consensus, clinical decision-making, evidence summaries, systematic reviews, and randomized controlled trials.

2.2. Literature searching

According to the top-down principle of the “6S” model of evidence-based resources [19], the following databases were searched: (1) Decision support systems: UpToDate, BMJ Best Practice; (2) Guideline websites: Guidelines International Network (GIN), The National Institute for Health and Care Excellence (NICE), Registered Nurses’ Association of Ontario (RNAO), Scottish Intercollegiate Guidelines Network (SIGN), New Zealand Guidelines Group (NZGG), National Health and Medical Research Council of Australia (NHMRC), National Guideline Clearinghouse (NGC), Medlive, American Medical Association (AMA); (3) Databases: Cochrane Library, JBI Evidence-Based Healthcare Database, PubMed, Web of Science, CINAHL, Embase, China National Knowledge Infrastructure (CNKI), Wanfang Database, and VIP; (4) Professional Organization Websites: World Union of Wound Healing Societies (WUWHS), Association for the Advancement of Wound Care (AAWC), International Wound Infection Institute (IWII), Australian Wound Management Association (AWMA), The World Council of Enterostomal Therapists (WCET), Wound, Ostomy, and Continence Nurses Society (WOCN), American Society of Colon and Rectal Surgeons (ASCRS), United Ostomy Associations of America (UOAA), Nurses Specialized in Wound, Ostomy, and Continence Canada (NSWOCC), and Chinese Nursing Association.

Moreover, a systematic search for grey literature was explicitly conducted to identify ongoing or unpublished studies and minimize publication bias. The search targeted the following resources: clinical trial registries, including ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), European Union Clinical Trials Register, Australia New Zealand Clinical Trials Registry (ANZCTR), and China Clinical Trial Registration Center (ChiCTR); and the grey literature database OpenGrey. Search strategies in these resources utilized key terms from our main search strategy, such as “platelet-rich plasma” and “chronic wound”, adapted to the functionality of each site.

The search strategy was conducted using a combination of subject terms, free terms, and Boolean operators, while also tracing citations. The search period was from the establishment of the database until May 1, 2025. The search terms included: ‘chronic wound∗ OR non healing wound∗ OR hard to heal wound∗ OR hard healing wound∗ OR pressure ulcer∗ OR bedsore∗ OR pressure sore∗ OR pressure injur∗ OR decubitus ulcer∗ OR varicose ulcer∗ OR venous ulcer∗ OR stasis ulcer∗ OR diabetic foot OR diabetic feet OR arterial ulcer∗’ AND ‘platelet-rich plasma OR PRP OR autologous conditioned plasma OR platelet gel OR platelet concentrate OR platelet-derived growth factor’ AND ‘guideline∗ OR consensus OR systematic review OR meta-analysis OR best practice OR evidence summar∗ OR randomized controlled trial’. As an example, the search strategy on PubMed is shown in Fig. 1.

Fig. 1.

Search strategies of PubMed database.

2.3. Inclusion and exclusion criteria

Inclusion Criteria: (1) study subjects are chronic wound patients aged ≥18 years; (2) the content involves platelet-rich plasma; (3) types of literature include guidelines, expert consensus, clinical decisions, evidence summaries, systematic reviews, and randomized controlled trials; (4) published in Chinese or English.

Exclusion Criteria: (1) incomplete information or full text not available; (2) duplicate publications or updated versions; (3) registration protocols; (4) guideline interpretations; (5) quality assessment rated as low quality.

2.4. Literature screening

After the literature search, all articles were imported into Endnote, and duplicates were removed. The literature screening process was independently performed by two researchers (Xinru Zhang and Xingxing Zhang) with expertise in evidence-based nursing. They initially reviewed titles, abstracts, and keywords to preliminarily identify studies that met the inclusion and exclusion criteria, then read the full text to confirm the final inclusion. If disagreements occurred during the screening process, a third researcher (Luxin Wang) was consulted to determine the inclusion status of the literature.

2.5. Literature quality assessment

The included guidelines were independently evaluated by four researchers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) [20]. This tool includes six domains and 23 items, with each item rated on a 7-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). The final score for each domain was calculated using the standardized percentage, as follows: (obtained score - minimum possible score)/(maximum possible score - minimum possible score) × 100 %. Based on the standardized percentages in each domain, the guidelines were classified into three levels: Level A: If the standardized percentage in all six domains is ≥ 60 %, it is classified as high quality and can be directly recommended. Level B: If the standardized percentage is <60 % and ≥30 % in at least three domains, it is classified as moderate quality and needs revision before recommendation. Level C: If the standardized percentage is <30 % in at least three domains, it is considered low quality and not recommended for use [21].

The literature evaluation standards formulated by the JBI Evidence-Based Healthcare Center (2016 version) were used to assess systematic reviews, randomized controlled trials, and expert consensus [19]. For systematic reviews, if more than four items are rated “No”, it is considered low quality. For randomized controlled trials, if more than four items are rated “No”, it is considered low quality. For expert consensus, if more than two items are rated “No”, it is considered low quality [22]. The quality assessment was independently performed by researchers with expertise in evidence-based knowledge. Four evaluators (Xinru Zhang, Xingxing Zhang, Luxin Wang and Meiyan Lin) were involved in the assessment of guidelines, while two evaluators (Xinru Zhang and Xingxing Zhang) assessed other types of literature. In case of disagreements, a clinical nursing expert (Mulan Zhu) was added to discuss and decide whether to include or exclude the literature.

2.6. Evidence summary and grading

Two researchers (Xinru Zhang and Xingxing Zhang) trained in evidence-based nursing independently extracted information such as the type of literature, title, and the original evidence content. In case of discrepancies in the extracted evidence, an expert (Mulan Zhu) with a background in wound care was involved to determine the content. The evidence extraction process followed these principles [17]: (1) When the content is consistent, evidence is selected to represent the concentrated expertise; (2) When different evidence sources are similar or complementary, they are combined into a unified evidence; (3) When there are significant differences among multiple pieces of evidence, the highest quality or most recently published data from authoritative, evidence-based journals is chosen.

The JBI Evidence Pre-Grading and Evidence Recommendation Level System (2014 version) was used to classify the evidence level [19]. Depending on the type of research design, the evidence levels range from 1a to 5c. The stricter the research design, the higher the evidence level, with 1a being the highest, followed by progressively lower levels. Based on the FAME evidence structure, the evidence recommendation levels are classified as Grade A (strong recommendation) and Grade B (weak recommendation) [19].

3. Results

3.1. Basic characteristics of included studies

The initial search identified 1950 articles. Following duplicate removal, 1583 articles remained. After screening titles and abstracts, 182 articles were retained for full-text review. Ultimately, 17 articles met the inclusion criteria: three guidelines [[23], [24], [25]], five expert consensus statements [16,[26], [27], [28], [29]], and nine systematic reviews [[12], [13], [14], [15],[30], [31], [32], [33], [34]]. The PRISMA flow diagram of the literature search process is shown in Fig. 2, and the basic characteristics of the included studies are presented in Table 1.

Fig. 2.

Literature screening process.

Table 1.

General information of the included literature (N = 17).

Author	Year	Study location	Literature source	Type	Content
Gould LJ et al. [24]	2024	USA	WUWHS	Guidelines	Pressure injury treatment guidelines
Lavery LA et al. [23]	2024	USA	WUWHS	Guidelines	Diabetic foot ulcer treatment guidelines
Wang A et al. [25]	2020	China	Pubmed	Guidelines	Multidisciplinary prevention and management guidelines for diabetic foot
Eymard F et al. [26]	2025	France	Pubmed	Expert Consensus	Indications and contraindications for platelet-rich plasma injections
Cheng Z et al. [27]	2022	China	Medlive	Expert Consensus	Technical specifications for autologous platelet-rich plasma preparation: expert consensus
Shan G et al. [28]	2021	China	CNKI	Expert Consensus	Expert consensus on autologous platelet-rich plasma preparation
Chinese Geriatric Society Burn and Trauma Branch [16]	2020	China	Medlive	Expert Consensus	Expert consensus on concentrated platelet products in wound healing applications
Guo G et al. [29]	2020	China	Medlive	Expert Consensus	National expert consensus on surgical treatment of diabetic foot with refractory wounds
Hu Z et al. [12]	2024	China	Pubmed	Systematic Review	Efficacy and safety of platelet-rich plasma in treating venous ulcers
OuYang H et al. [13]	2023	China	Pubmed	Systematic Review	Systematic review of platelet-rich plasma for diabetic foot ulcers
Qu S et al. [31]	2022	China	Pubmed	Systematic Review	Systematic review of platelet-rich plasma in chronic skin ulcer treatment
Qu W et al. [32]	2021	China	Pubmed	Systematic Review	Efficacy and safety of platelet-rich plasma in chronic wound treatment
Oliveira BGRB et al. [33]	2020	Brazil	Pubmed	Systematic Review	Cost-Effectiveness of platelet-rich plasma in venous leg ulcer healing
Li T et al. [15]	2020	China	CNKI	Systematic Review	Meta-Analysis of autologous platelet-rich plasma for diabetic chronic skin ulcers
Xia Y et al. [14]	2019	China	Pubmed	Systematic Review	Efficacy of platelet-rich plasma dressings in chronic non-healing wounds
Niu C et al. [34]	2019	China	CNKI	Systematic Review	Platelet-rich plasma for diabetic foot ulcers: efficacy and safety Meta-Analysis
Martinez-Zapata MJ et al. [30]	2016	Spain	Pubmed	Systematic Review	Autologous platelet-rich plasma for treating chronic wounds

3.2. Quality assessment results of included studies

3.2.1. Quality assessment of guidelines

A total of 3 guidelines were included. All three guidelines had a standardized percentage of ≥30 % in at least 3 domains, and were rated as Grade B. The quality assessment results of the guidelines are shown in Table 2.

Table 2.

Quality evaluation results of guidelines (N =3).

Guideline	Percentage of Field Standardisation (%)						≥60 %	≥30 %	Quality Grade
	Scope and Purpose	Stakeholder Involvement	Rigour	Clarity	Applicability	Independence
Gould LJ et al. (2024) [24]	89.29	63.09	54.91	96.43	51.79	100.00	4	6	B
Lavery LA et al. (2024) [23]	83.33	58.33	52.68	90.48	46.43	83.93	3	6	B
Wang A et al. (2020) [25]	92.86	63.10	52.68	98.81	57.14	92.86	4	6	B
Mean (SD)	88.49 (4.81)	61.51 (2.75)	53.42 (1.29)	95.24 (4.29)	51.79 (5.36)	92.26 (8.05)

3.2.2. Quality assessment of expert consensus

This study included 5 expert consensus statements. The included studies were affirmative for items 2, 3, and 5. Shan's study [28] was negative for item 1, while three studies [26,28,29] were unclear for item 6, and the study by the Chinese Geriatric Society Burn and Trauma Branch [16] was negative for item 6. The overall quality was moderate, and the studies were included. The specific quality assessment results are shown in Table 3.

Table 3.

Quality evaluation results of expert consensus (N = 5).

Expert consensus	Q1	Q2	Q3	Q4	Q5	Q6
Eymard F et al. (2025) [26]	Yes	Yes	Yes	Yes	Yes	Unclear
Cheng Z et al. (2022) [27]	Yes	Yes	Yes	Yes	Yes	Yes
Shan G et al. (2021) [28]	No	Yes	Yes	Yes	Yes	Unclear
Chinese Geriatric Society Burn and Trauma Branch. (2020) [16]	Yes	Yes	Yes	Yes	Yes	No
Guo G et al. (2020) [29]	Yes	Yes	Yes	No	Yes	Unclear
Studies Meeting Criterion, n (%)	4 (80 %)	5 (100 %)	5 (100 %)	4 (80 %)	5 (100 %)	1 (20 %)

NOTE: Q1: Is the source of the opinion clearly identified? Q2: Does the source of opinion have standing in the field of expertise? Q3: Are the interests of the relevant population the central focus of the opinion? Q4: Does the opinion demonstrate a logically defended argument to support the conclusions drawn? Q5: Is there reference to the extant literature? Q6: Is any incongruence with the literature/sources logically defended?.

3.2.3. Quality assessment of systematic reviews

This study included 9 systematic reviews. Three studies [14,15,33] were unclear for item 3, and five studies [12,13,15,30,34] were negative for item 4. All other items were affirmative. The overall quality was high, and the studies were included. The specific quality assessment results are shown in Table 4.

Table 4.

Quality evaluation results of systematic review (N = 9).

Systematic review	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11
Hu Z et al. (2024) [12]	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
OuYang H et al. (2023) [13]	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Qu S et al. (2022) [31]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Qu W et al. (2021) [32]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Oliveira BGRB et al. (2020) [33]	Yes	Yes	Unclear	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Li T et al. (2020) [15]	Yes	Yes	Unclear	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Xia Y et al. (2019) [14]	Yes	Yes	Unclear	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Niu C et al. (2019) [34]	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Martinez-Zapata MJ et al. (2016) [30]	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Studies Meeting Criterion, n (%)	9 (100 %)	9 (100 %)	7 (78 %)	4 (44 %)	9 (100 %)	9 (100 %)	9 (100 %)	9 (100 %)	9 (100 %)	9 (100 %)	9 (100 %)

Note: Q1: Is the review question clearly and explicitly stated? Q2: Were the inclusion criteria appropriate for the review question? Q3: Was the search strategy appropriate? Q4: Were the sources and resources used to search for studies adequate? Q5: Were the criteria for appraising studies appropriate? Q6: Was critical appraisal conducted by two or more reviewers independently? Q7: Were there methods to minimize errors in data extraction? Q8: Were the methods used to combine studies appropriate? Q9: Was the likelihood of publication bias assessed? Q10: Were recommendations for policy and/or practice supported by the reported data? Q11: Were the specific directives for new research appropriate?.

3.3. Summary of evidence

By synthesizing the evidence related to PRP therapy, 27 pieces of evidence were summarized in six areas: application principles, indications and contraindications, pre-treatment preparations, treatment protocols, efficacy monitoring, and management strategies, as shown in Table 5. Given that the efficacy and supporting evidence for PRP vary considerably across different chronic wound types, an evidence map summarizing this specificity is presented in Table 6.

Table 5.

Evidence summary and clinical recommendations for PRP therapy in chronic wounds.

Category	Sub-category	Evidence Content	Clinical Action	Levela	Recommend Gradeb	Basis
Application Principles	Multidisciplinary Assessment	1. A comprehensive risk-benefit assessment by multidisciplinary clinical experts is required prior to PRP therapy, integrating patient medical history, wound characteristics, comorbidities, and alternative therapies [16,26].	Conduct multidisciplinary team assessment before PRP treatment.	5b	B	Expert Consensus
	Informed Consent	2. Due to significant individual variability in PRP treatment outcomes, patients must be informed of potential risks, benefits, and possible outcomes, and provide informed consent before treatment [16,26].	Obtain detailed informed consent after a detailed discussion of uncertainties.	5b	B	Expert Consensus
Indications and Contraindications	Indications	3. PRP can be used for: acute wounds; chronic wounds such as diabetic ulcers (DU), venous ulcers (VU), pressure injuries unresponsive to initial comprehensive therapy and/or surgical repair, neurotrophic ulcers, radiation-induced ulcers, postoperative non-healing wounds, etc., if no improvement (wound area reduction <50 %) is observed after 4–6 weeks of standard treatment; pilonidal sinus; burns, grafted areas, donor sites; and various types of scars [16,24,25].	Consider PRP for refractory chronic wounds. Refer to Table 6 for evidence strength by specific wound type.	5b	B	Guideline, Expert Consensus, Systematic Review
	Absolute Contraindications	4. Do not use PRP in cases of platelet dysfunction syndrome, severe thrombocytopenia, hemodynamic instability, hypersplenism, sepsis (systemic infection), or local infection at the treatment site [27].	Avoid PRP in patients with specific hematologic, infectious, or instability contraindications.	5b	B	Expert Consensus
	Relative Contraindications	5#. Use PRP with caution if the patient has recently used NSAIDs (<48 h), corticosteroids (local<1 month; systemic<2 weeks), or anticoagulants (<5 days) [16,26,27].	Evaluate and potentially adjust medications before PRP.	5b	B	Expert Consensus
	Relative Contraindications	6#. Use PRP with caution in patients with recent fever/illness, active/unstable malignancies, low hemoglobin (<100 g/L) or platelet count (<100 × 109/L), or smoking/alcohol abuse [16,26,27].	Assess and optimize overall health status before PRP.
Pre-Treatment Preparations	Comprehensive Assessment	7. Conduct a comprehensive patient assessment before treatment [16,26,27].	Perform and document a structured pre-PRP assessment.	5b	B	Expert Consensus
	History Taking	8. Assessment should include medical history, wound duration, medication history, allergies, prior treatments, and patient expectations [27].	Systematically document the patient's full medical and wound history.	5b	B	Expert Consensus
	Physical Examination	9. Document wound location, size, depth, base condition, exudate characteristics, and surrounding skin status [27].	Perform a detailed wound physical assessment using a standardized tool.	5b	B	Expert Consensus
	Laboratory Tests	10. Perform complete blood count (CBC) and coagulation profile; evaluate glycemic control in diabetics [16].	Obtain CBC, coagulation studies, and assess glucose control.	5b	B	Expert Consensus
	Vascular Assessment	11. Measure ankle-brachial index (ABI) and assess for vascular lumen stenosis [16].	Measure ABI; avoid PRP if significant peripheral arterial disease is present unless revascularized.	5b	B	Expert Consensus
	Physiological Optimization	12. Correct underlying conditions before PRP: albumin >30 g/L#, hemoglobin ≥100 g/L#, WBC >3 × 109/L#, blood glucose <11 mmol/L#, correct hypoxemia/electrolyte imbalances, and improve tissue perfusion [16].	Optimize the patient's systemic condition (nutrition, glycemic control) before treatment.	5b	B	Expert Consensus
Treatment Protocols	Frequency	13. Applied at least once every 1–2 weeks#; may be used more frequently if the patient's condition permits [16].	Administer PRP treatments on a weekly or bi-weekly schedule.	5b	B	Expert Consensus
	Course	14. 3–5 days per application, with 3 or 4 applications constituting one treatment course [16]#.	Plan for an initial treatment course of 3–4 PRP applications.	5b	B	Expert Consensus
	Administration Method	15. PRP can be administered via injection around the wound edge, topical application (spray, packing), or a combination [16].	Choose application method (injection/topical/combined) based on wound depth and location.	5b	B	Expert Consensus
	Combination Therapy	16. PRP may be combined with other therapies like fat grafting, negative pressure wound therapy, phototherapy, or functional dressings [13,16].	Consider combining PRP with other advanced wound care modalities to enhance efficacy.	5b	B	Expert Consensus, Systematic Review
Efficacy Monitoring	Healing Outcomes	17. Monitor wound healing using indicators like wound area/depth, complete healing rate, percentage area reduction, time to healing, and recurrence rate [[12], [13], [14], [15],[31], [32], [33], [34]].	Regularly measure and photograph the wound to track healing progress objectively.	1a	A	Systematic Review
	Safety Outcomes	18. Monitor for adverse events including infection rate and irritant dermatitis [[12], [13], [14], [15],[31], [32], [33], [34]].	Assess for signs of infection or adverse reactions at each dressing change.	1a	A	Systematic Review
	Patient and Economic Outcomes	19. Assess patient experience using pain scores (visual analogue scale, VAS), quality of life (health-related quality of life, HRQoL), hospitalization costs and length of stay [[12], [13], [14], [15],[30], [31], [32], [33], [34]].	Use patient-reported outcome measures (e.g., VAS for pain) to evaluate treatment impact.	1a	A	Systematic Review
	Evaluation Timing	20. Evaluate PRP efficacy after 3 weeks of application. If ineffective, switch to other treatments promptly# [16].	Re-evaluate wound healing at 3 weeks; discontinue PRP if ineffective.	5b	B	Expert Consensus
Management Strategies	Wound Bed Preparation	21. PRP must be applied to debrided and relatively aseptic wounds. Necrotic tissue must be removed, and infection must be controlled prior to treatment [16].	Surgically debride the wound and control infection prior to PRP application.	5b	B	Expert Consensus
	Preparation Asepsis	22. The preparation process of PRP should strictly comply with sterile operation and relevant operating standards and guidelines [27].	Adhere to a standardized, sterile protocol for PRP preparation.	5b	B	Expert Consensus
	Blood Volume	23. The typical blood volume for PRP preparation is 8–50 ml#, adjustable based on required PRP volume and platelet enrichment [27].	Collect 8–50 ml blood for PRP preparation as needed.	5b	B	Expert Consensus
	Skin Disinfection	24. Perform rigorous skin disinfection before topical or injectable PRP use [16].	Prepare the wound and surrounding skin as for a sterile procedure.	5b	B	Expert Consensus
	Menstruation	25. Avoid PRP treatment during menstruation [27].	Schedule PRP treatment outside of the patient's menstrual period.	5b	B	Expert Consensus
	Post-Treatment Care	26. Keep puncture sites clean and dry to prevent infection [27].	Provide clear post-procedure care instructions to the patient.	5b	B	Expert Consensus
	Adverse Effects	27. Be aware of potential adverse effects like injection site pain, swelling, and local infection [12,13].	Counsel patients on potential adverse effects and advise them to report any concerns promptly.	1a	A	Systematic Review

Note: ^a: According to the JBI (2014) evidence pre-grading system. Level 1 represents the highest quality evidence (e.g., RCT), while Level 5 represents the lowest (e.g., expert opinion). ^b: Grade A represents a strong recommendation for application, supported by high-level, reliable evidence. Grade B represents a weak recommendation for application, where the evidence is of lower quality, or where the benefits and applicability are less certain, necessitating careful clinical judgment. The strength of a recommendation never exceeds the level of the underlying evidence. ^#: Specific thresholds or criteria that are primarily based on expert consensus.

Table 6.

Evidence map and recommendation summary for PRP therapy by chronic wound type.

Wound Type	Key Efficacy Outcomes	Evidence Level	Recommendation Grade	Clinical Guidance
Venous Ulcers	Complete ulcer healing [12] (OR = 5.06, 95 % confidence interval [CI]: 2.35–10.89); Percentage of ulcer area reduction [12] (Mean Difference [MD] = 47 %, 95 % CI: 32 %–62 %); Time for complete healing [12] (MD = −3.25, 95 % CI: 4.06 to −2.43); Recurrence [12] (OR = 0.16, 95 % CI: 0.05–0.50)	1a	A	Consistent positive findings across multiple meta-analyses [12,33]. Recommended as an adjunctive therapy.
Diabetic Foot Ulcers	Healing rate [13] (OR = 4.37, 95 % CI: 3.02–6.33); Healing time [13] (MD = −3.21, 95 % CI: 3.83 to −2.59); Ulcer area [13] (MD = 5.67, 95 % CI: 0.77 to 12.11)	1a	B	Positive signal, but larger confidence intervals and higher heterogeneity than VUs [13,15,34]. Should be considered as an option, considering individual context.
Pressure Injuries	Limited and inconsistent data	5b	B	Evidence is insufficient to establish efficacy [24]. Use, if considered, should be highly individualized and within a study context.
Arterial Ulcers	Limited and inconsistent data	5b	B	Evidence is insufficient to establish efficacy [16]. Use, if considered, should be highly individualized and within a study context.

Note: This table should be referenced when applying the general evidence from Table 5 to specific clinical scenarios. Outcomes are hierarchically ordered for clinical interpretation, with complete wound healing representing a more definitive endpoint than reduction in wound area.

4. Discussion

This study is evidence-based and uses the PIPOST framework to define the evidence question. A comprehensive search of databases and websites was conducted based on the 6S model, and standardized tools such as AGREE II were used to assess the quality of the included literature. After strict screening by the research team, 3 guidelines, 5 expert consensus statements, and 9 systematic reviews were included. A total of 27 pieces of evidence were extracted, covering six areas: application principles, indications and contraindications, pre-treatment preparations, treatment protocols, efficacy monitoring, and management strategies. The evidence formation process was scientific and rigorous, providing scientific guidance for the clinical application and practice of PRP therapy in chronic wounds.

4.1. Efficacy is not uniform and varies significantly by wound type

A key finding of this review is that PRP's efficacy and supporting evidence vary significantly by wound type (Table 6). When interpreting this evidence, it is important to consider the hierarchy of wound healing outcomes. Complete wound healing is the most definitive patient-centric endpoint, while reduction in wound area is a valuable and commonly reported intermediate metric that indicates positive biological activity. The pooled effect sizes for these and other outcomes (e.g., healing time, safety) are detailed in Table 6. A strong recommendation (Grade A) is supported for venous ulcers, where meta-analyses consistently show improved healing rates and time to healing [12,30,33]. For diabetic foot ulcers, a positive but more heterogeneous effect warrants a weaker recommendation (Grade B) [13,15,34]. In contrast, the same Grade B for pressure injuries and arterial ulcers reflects a different evidence basis—not RCT-derived efficacy, but low-quality evidence (Level 5) from guidelines and expert consensus [16,24]. This highlights the current insufficiency of robust data for these wounds and emphasizes that PRP must not precede standard care (e.g., offloading or revascularization). Clinicians must therefore avoid extrapolating results across wound types and apply the general indications in Table 5 within the specific evidence context outlined in Table 6.

It is also important to note that recent authoritative guidelines, including the 2023–2024 WHS updates, have not yet endorsed PRP as a standard therapy, citing considerable heterogeneity, risk of bias, and a lack of standardized protocols across studies [23,24]. These methodological concerns are further compounded by practical barriers to implementation—such as equipment costs, the need for specialized training, and variable insurance coverage—which together contribute to the persistent evidence-to-practice gap. In this context, the present evidence summary serves a critical role. By systematically retrieving, appraising, and synthesizing available evidence into clinically actionable recommendations, this study provides a consolidated, evidence-informed framework to support decision-making regarding PRP use. The following sections elaborate on the core components of this framework.

4.2. Comprehensive risk-benefit assessment and informed consent are core principles of PRP treatment

Evidence 1–2 in Table 5 indicates that the clinical application of PRP must strictly adhere to the core principles of multidisciplinary assessment and patient informed consent. Most chronic wound patients have complex etiologies and significant variations in their overall health status. To ensure the safety of the treatment plan, a comprehensive evaluation by a multidisciplinary expert team must be conducted before selecting PRP as an auxiliary treatment [26]. PRP preparation is based on the patient's own peripheral blood, with significant individual differences in platelet activity, growth factor concentrations, and other factors. Furthermore, the standardization of cell-based therapies is difficult to control, leading to certain uncertainties in PRP treatment [13]. Therefore, it is necessary to clearly inform patients of the potential benefits and risks, and PRP can only be chosen as an adjunctive therapy after obtaining fully informed consent from the patient. This highlights the importance of clinicians and wound care specialists enhancing communication with patients and their families before selecting PRP, informing them of the various possible outcomes, and obtaining informed consent.

Evidence 3–6 in Table 5 clarify the indications and contraindications for PRP treatment. From the perspectives of patient compliance, safety, and cost-effectiveness, PRP can be used as an adjunctive therapy for the repair of many patients chronic wounds [24,25]. However, it must strictly avoid absolute contraindications, such as sepsis and platelet function disorder syndrome [27]. For relative contraindications, such as diabetic patients with abnormal ankle-brachial index [16] or patients with hematologic malignancies who are under diagnosis or have unstable conditions [26], PRP should be used cautiously after prioritizing the improvement of overall health, combined with individualized decision-making. However, most current studies do not consider the clinical staging of chronic wounds, wound size, and infection severity, resulting in existing evidence being unable to accurately demonstrate the applicability of PRP. In the future, large-scale, multi-center randomized controlled trials could be conducted to fill this gap.

4.3. Identification of potential risks and pre-treatment optimization are prerequisites for ensuring efficacy

After a multidisciplinary assessment, patients with chronic wounds who require PRP therapy should undergo a comprehensive evaluation by medical staff before starting treatment. This evaluation should include medical history collection, physical examination, laboratory tests, and vascular assessment to identify potential risks and optimize the treatment plan [16,26,27]. For specific details, see evidence 7–11 in Table 5. The core reason for conducting a comprehensive assessment is risk stratification and individualized treatment needs. Patients with chronic wound often have concomitant vascular disease, metabolic disorders, or coagulation dysfunction, which may lead to treatment complications or negate efficacy. Expert consensus points out that PRP treatment is ineffective when vascular lumen stenosis exceeds 75 % [16]. Research by Smith et al. indicates that higher BMI, low glomerular filtration rate, large wound area, presence of scar tissue, infection, and nutritional deficiencies can all contribute to PRP failure or reduced efficacy [35]. If controllable risk factors such as mild hypoalbuminemia or blood glucose fluctuations are identified before treatment, it is recommended to establish a 1–2 week pre-treatment period to optimize the patient's overall condition. PRP treatment should be initiated after meeting the standards outlined in evidence 12. The current thresholds for biomarkers (such as albumin, hemoglobin, etc.) and specific risk factors (such as the degree of vascular stenosis, ankle-brachial index thresholds) are mostly based on expert consensus [16,27], with low-quality evidence. Furthermore, there is a significant lack of safety and efficacy data for special populations, such as those with chronic kidney disease or those using anticoagulant/antiplatelet drugs. High-quality prospective studies are urgently needed to establish evidence-based guidelines, providing more accurate evidence support for clinical decision-making.

4.4. Individualized treatment strategies and combined interventions are key to enhancing efficacy

Evidence 13–16 in Table 5 provides specific clinical protocols for PRP treatment of chronic wounds. Based on expert consensus [16], it is recommended that treatments be applied once every 1–2 weeks, each lasting 3–5 days, with 3 or 4 treatments per course. The frequency and duration of treatment can be dynamically adjusted according to the patient's overall health status and wound healing progress. In addition, combining PRP with other wound healing techniques, such as fat grafting, negative pressure wound therapy, phototherapy, and functional dressings, can enhance its efficacy [13,16]. A randomized controlled trial showed that adding PRP to fat grafts can increase neovascularization and graft survival in diabetic foot ulcers [36]. A meta-analysis by Yin et al. demonstrated that, compared to the control group, patients with stage 2 or 3 diabetic foot ulcers treated with vacuum-assisted closure therapy combined with PRP had higher ulcer healing rates, shorter healing times, and reduced hospital stays [37]. However, existing evidence does not provide a clear conclusion on the optimal application method. It needs to be chosen based on wound depth and anatomical location, such as injecting at the wound edges, applying directly to the wound (or using a spray gun, filling), or using a combination of both [16]. Evidence 13–16 mainly comes from expert consensus and has a lower evidence level. Further high-quality randomized controlled trials are needed in the future to determine the best intervention model for different application scenarios and explore more potential individualized treatment options.

4.5. Dynamic efficacy monitoring and comprehensive risk management are essential for ensuring safe treatment

Evidence 17–20 in Table 5 suggests that the effectiveness of PRP treatment should be assessed using multidimensional indicators three weeks after application [16]. A standardized file should be established for the patient throughout the treatment, including descriptions of the disease course, medication history, and photographic records of the wound, as well as infrared or ultrasound imaging data for longitudinal comparison of healing progress. If the effectiveness is not clearly apparent, alternative effective methods should be immediately adopted to avoid delaying the treatment window [16]. However, while most studies report the complete healing rate and complete healing time of the wound [38,39], the methods for quantifying wound area reduction vary. Some studies use absolute values, while others use percentages, which weakens the comparability of data between studies [12]. To more accurately assess the effectiveness of PRP, it is recommended to use standardized measurement techniques to consistently report changes in wound size. There is limited research on economic burden indicators such as hospitalization time and costs. The existing studies have small sample sizes and lack cost-effectiveness analyses of different treatment protocols. It is recommended to conduct large-scale real-world studies to quantify the impact of PRP treatment on healthcare resource consumption and provide evidence for health policy formulation.

Existing research results indicate that there are significant differences, even completely opposing results, in dynamic efficacy monitoring for different patients [12,13]. One major reason for this phenomenon is the lack of authoritative standards in the extraction and preparation of PRP. Factors such as centrifugal force, centrifugation time, and the type of activator used in the PRP preparation process have been shown to significantly affect the platelet concentration in PRP products [12,13]. Low platelet concentrations are detrimental to wound healing, while excessively high concentrations may disrupt the healing process [35]. Another reason is the lack of standardized management in the PRP treatment process. Although PRP has some antibacterial effects [13], it can also promote the proliferation of pseudomonas aeruginosa, anaerobic bacteria, fungi, and other pathogens [16], which can weaken the efficacy of PRP. Therefore, infection control should be maintained throughout the entire PRP treatment process. It is recommended to debride chronic wounds before applying PRP and strictly follow aseptic operation guidelines throughout the PRP preparation and injection process [16]. Based on expert consensus, the comprehensive risk management strategies for the PRP application process summarized in this study are shown in Evidence 21–27 in Table 5. However, there is currently insufficient data to support key parameters such as centrifugation time, activator type, and infection monitoring indicators. It is recommended that researchers in related fields conduct high-quality studies to establish standardized operating protocols covering the entire “preparation-application” chain, clarify the critical parameters in the preparation process, and develop anti-infection management pathways to enhance the stability and reproducibility of PRP treatment.

4.6. High heterogeneity in PRP preparation and application constrains generalizability and adoption

A critical limitation hindering the interpretation and clinical adoption of PRP therapy is the profound heterogeneity in preparation and application protocols across studies. Significant variations exist in centrifugation methods, platelet/leukocyte concentrations, activator use, and application techniques (e.g., injection vs. topical) [12,13,16]. This lack of standardization means that “PRP” constitutes a class of therapies rather than a single, defined intervention, which directly limits the reproducibility and generalizability of the positive signals observed in meta-analyses. It is therefore essential to clarify that the treatment parameters in Table 5 represent consensus-based recommendations for clinical feasibility, not empirically optimized regimens.

Looking forward, emerging areas such as the use of allogeneic (donor-sourced) PRP offer a potential alternative for patients in whom an autologous blood draw is unsuitable, though the current evidence base remains limited and requires further validation [40]. Furthermore, it is crucial to recognize that robust evidence is particularly sparse for key patient subgroups. This includes individuals with chronic kidney disease, immunocompromised status, those on concurrent anticoagulant or antiplatelet therapy, older adults, and patients with radiation-induced wounds. The efficacy and safety of PRP in these populations cannot be extrapolated from existing studies, and their management should be approached with caution. These groups, along with the refinement of standardized protocols, represent critical priorities for future high-quality, targeted clinical research.

Although this study provides a comprehensive summary of the timing and management strategies for PRP application in chronic wound patients, there are still some limitations. The streamlined approach of this evidence summary, while efficient, means that our search may not have been exhaustive; consequently, some clinical trials or non-English publications might have been overlooked. Additionally, the generalizability of our recommendations may be affected by the clinical and methodological diversity observed in the source literature. Finally, our database selection was confined to major Chinese and English sources, which might have omitted regional evidence.

5. Conclusions

This study summarizes 27 pieces of evidence related to PRP therapy for chronic wounds, covering six aspects: application principles, indications and contraindications, pre-treatment preparations, treatment protocols, efficacy monitoring, and management strategies. The findings demonstrate that PRP therapy can serve as an adjunctive treatment for specific chronic wounds, with the strongest evidence for venous ulcers, moderate support for diabetic foot ulcers, and currently insufficient evidence for pressure injuries or arterial ulcers. Clinicians and wound care specialists should thoroughly evaluate the applicability and optimal timing of PRP, tailoring its use to specific clinical contexts while considering patient-specific factors and preferences to enhance wound healing and mitigate the global disease burden of chronic wounds. Future high-quality clinical studies are warranted to strengthen the evidence base and advance evidence-based practice.

Authors’ contributions

Xinru Zhang and Xingxing Zhang: Project administration and drafting. Luxin Wang, Li Zhen and Meiyan Lin: Data analysis and validation. Yanan Li, Lihong Gong and Haiting Zeng: Data analysis and visualization. Weiqing Ruan and Mulan Zhu: Supervision and drafting and editing.All authors read and approved the final manuscript.

Funding

This study was supported by the Medical Scientific Research Foundation of Guangdong (NO.A2024705), the Research Fund of Nanfang Hospital, Southern Medical University (No. 2024H003).

Declaration of competing interest

The authors declare no conflicts of interest.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.