A Comparative Study on Therapeutic Efficacy of Autologous Platelet Rich Fibrin Matrix Versus Zinc Oxide And Phenytoin Paste in Non Healing Ulcers

Abstract

Context:

A non-healing ulcer occurs due to multiple causes and possesses a great impact on the quality of life. Autologous platelet-rich fibrin and the application of a triple combination paste (zinc oxide, phenytoin, and mupirocin ointment) have emerged with a good response in the treatment of non-healing ulcers.

Aims:

To compare the therapeutic efficacy of autologous platelet-rich fibrin matrix versus the triple combination paste (zinc oxide, phenytoin, and mupirocin ointment) in non-healing ulcers.

Settings and Design:

Hospital-based interventional comparative study.

Materials and Method:

Twenty-four patients with non-healing ulcers were randomly divided into two groups. One group received platelet-rich fibrin (PRF) therapy every week for up to 5 weeks and the second group applied triple combination paste (zinc oxide, phenytoin, and mupirocin ointment) again for 5 weeks. In the end, the ulcer area was measured.

Statistical Analysis Used:

Student's paired t-test was used to evaluate the correlations between variables. A P-value of < 0.05 was considered significant.

Results:

Group A showed a mean reduction in the ulcer area by 8.26 mm² (75.99%). Group B showed a mean reduction in the ulcer area by 4.799 mm² (47.75%), which was statistically significant with a P-value of 0.004.

Conclusion:

We conclude that autologous platelet-rich fibrin matrix is much more effective than the triple combination paste (zinc oxide, phenytoin, and mupirocin ointment) in the treatment of non-healing ulcers.

Introduction

A non-healing ulcer is defined as an ulcer that does not heal even after 3 months of constant treatment. It is highly common among adult males and possesses major health problems and has a great impact on the quality of life due to distressing symptoms like pain, difficulty in walking, and impaired sleep. They can result secondary to arterial disease, venous disease, and diabetic neuropathy, metabolic disorders, hematological disorders, and infective diseases.

The autologous platelet-rich fibrin (PRF) is a simple and cost-effective method for the treatment of non-healing ulcers. It provides the necessary polypeptide growth factors that enhance tissue healing. One of them is transforming growth factor beta (TGF)-beta which is profibrotic and highly potent. These factors stimulate fibrosis and subcutaneous collagen deposition, increase biomechanical strength, and epithelial resurfacing and differentiation.

The recent literature shows autologous platelet-rich fibrin matrix (PRFM) being rich in growth factors. It is effective in the treatment of chronic non-healing ulcers.[1,2]

Phenytoin sodium causes hyperplasia of the gingiva[3] following its constant use; this is attributed to inflammation and/or fibrosis. This finding has prompted exploration of its role in wound healing.[4,5,6] Phenytoin increases fibroblast activity, decreases collagenase activity with the formation of granulation tissue. Mupirocin ointment possesses antibacterial action.

Topical zinc oxide promotes re-epithelization, and thus, has a role in wound healing. It is clinically established that the healing of leg ulcers is delayed in patients with a low level of zinc,[7] and thus, zinc can be given either orally or topically to improve healing in such patients.[8]

Aims and Objectives

Aim

To compare the therapeutic efficacy of autologous PRFM versus triple combination paste (zinc oxide, phenytoin, and mupirocin ointment) in non-healing ulcers.

Objectives

1. To know the efficacy of autologous PRFM versus triple combination paste (zinc oxide, phenytoin, and mupirocin ointment) in non-healing ulcers

2. To know the efficacy of autologous PRFM in non-healing ulcers.

3. To know the efficacy of triple combination paste (zinc oxide, phenytoin, and mupirocin ointment) in non-healing ulcers.

Subject and Method

The present clinical trial was conducted between August 2019 and 2020 in the Department of Dermatology, Venereology, and Leprosy. Written informed consent was taken from all the patients and ethical clearance was obtained (04.08.2019) from appropriate authorities of the college.

Study population

A total of 24 patients were included in the study with the age range 18–85 years. Patients with non-healing ulcers were selected from the outpatient department of Skin and VD.

Inclusion criteria

1. Patients with trophic ulcers due to Hansen disease or diabetes mellitus

2. Patients with stasis dermatitis

3. Pyoderma gangrenosum

4. Venous ulcer

5. Traumatic ulcer

6. Age group 18–85 years.

Exclusion criteria

1. Patients with age group below 18 years

2. Patients with a history of bleeding disorders

3. Anemia and other hematological disorders

4. Platelet count <1.5 lakhs/cu mm

5. Patients on anticoagulant medications (aspirin, warfarin, heparin)

6. Patients with malignant ulcers, pregnant and lactating females

The study population was randomized into two groups, i.e.,

1. Group A consisted of 12 patients on autologous PRFM.

2. Group B consisted of 12 patients on triple combination paste (zinc oxide, phenytoin, and mupirocin ointment).

Procedure

Preparation of PRFM

After taking informed consent, the length and breadth of the ulcer were measured. Under aseptic conditions, 10 mL of venous blood was collected from the median cubital vein and added to a sterile centrifugation tube without any anticoagulant. The tube was rotated at 3,000 rpm for 10 min. Three layers were obtained following this topmost acellular layer which is the platelet-poor plasma (PPP), the lowermost layer containing red blood cells (RBCs), and the middle layer containing the PRFM [Figure 1]. The upper layer (PPP) was discarded. The PRFM was separated from the RBCs at the base with the help of sterile forceps and scissors in a clean and sterile petri-dish. The matrix was then placed onto a sterile gauze and applied over the ulcer followed by the application of a secondary non-absorbable dressing. The patient was advised to take adequate rest. The dressing was removed after a period of minimum of 5 days. The procedure was repeated every week for up to five sittings. The healing of the ulcer was assessed, the area was calculated, and photographs were taken at the beginning and end of every week. The wound area was calculated using the formula for an ellipse: Length × width × 0.7854 (an ellipse is closer to a wound shape than a square or rectangle). The use of an ellipse for calculating the wound measurement has been used in randomized controlled trials in wound healing literature.[9,10]

Figure 1.

Platelet rich fibrin matrix

Preparation of triple combination paste (zinc oxide, phenytoin, and mupirocin ointment)

Under aseptic conditions, 10 phenytoin tablets (100 mg) were crushed finely in mortar and pestle. These were mixed with 10 g of zinc oxide powder and mupirocin ointment until a smooth paste was obtained. The patient was asked to apply it twice daily. At the beginning and every week, the healing of the ulcer was assessed, the area was calculated and photographs were taken [Tables 1 and 2]. The wound area was calculated using the formula for an ellipse: Length × width × 0.7854 as done in the preparation of the PRF matrix.

Table 1.

Patients on PRF treatment

Ulcer size at first visit (cm2)	2nd week (cm2)	3rd week (cm2)	4th week (cm2)	5th week (cm2)	Improvement (cm2)
13.665	10.354	8.760	5.218	2.314	11.351
11.545	8.09	5.932	4.093	2.563	8.982
6.597	4.482	2.003	1.378	0.985	5.612
5.654	5.027	4.472	4.034	3.872	1.782
12.566	10.785	8.403	6.935	5.854	6.712
8.796	7.057	5.373	3.647	1.276	7.52
16.681	10.934	7.953	5.785	3.527	13.154
18.692	14.463	8.646	5.874	2.176	16.516
1.963	1.293	0.945	0.564	0.231	1.732
12.534	8.759	5.346	4.779	3.294	9.24

Table 2.

Patients on triple combination paste (zinc oxide, phenytoin, and mupirocin ointment)

Ulcer size at first visit (cm2)	2nd week (cm2)	3rd week (cm2)	4th week (cm2)	5th week (cm2)	Improvement (cm2)
12.982	10.857	8.783	5.564	7.548	5.434
11.592	10.344	9.678	8.657	7.384	4.208
7.060	5.905	4.742	3.598	2.560	4.500
2.905	2.504	2.004	1.942	1.808	1.097
11.820	9.435	8.977	8.376	7.515	4.305
8.372	5.984	4.048	2.654	1.394	6.978
16.964	12.339	10.934	9.938	8.678	8.286
15.315	11.875	9.902	7.054	7.924	7.391
11.309	8.683	7.875	6.129	6.872	4.437
2.199	2.002	1.562	1.213	0.836	1.363

Results

Two patients from both groups A and B were excluded due to infrequent follow-up. So ultimately, there were 10 patients (50%) in each group and 20 patients in all. No statistically significant difference was observed between the two groups in terms of age, sex, site, and size of ulcer during enrolment. The ulcers were caused due to varied etiology. There were five patients with trophic ulcer (25%), two patients with stasis ulcer (10%), two patients with traumatic ulcer (10%), four patients with venous ulcer (20%), and seven patients with diabetic ulcer (35%). The ulcers were located on different sites. Seven patients had ulcers over the sole (35%), six patients had ulcers over the dorsum of the foot (20%), three of them had ulcers over the palm (15%), and six of them had ulcers over the leg (30%).

Group A showed a mean reduction in the ulcer area by 8.26 mm^{2 (}75.99%) which is highly significant (P-value = 0.0003) [Table 4]. Group B showed a mean reduction in the ulcer area by 4.799 mm² (47.75%) which is also significant (P-value = 0.017) [Table 3]. Two patients in group A achieved around 80% healing by 5 weeks and complete re-epithelialization by the end of 8 weeks [Figures 2 and 3] but none of the patients in group B achieved complete re-epithelialization [Figures 4 and 5].

Table 4.

The statistical difference between group A and group B was significant P=0.0042 (P< 0.05)

Groups	Group A	Group B	P
Improvement percentage (%)	75.994%	47.751%	0.0042

Table 3.

Improvement in both groups

Groups	Initial Size (mean±SD)	Final Size (mean±SD)	P
Group A	10.869±5.142	2.609±1.625	0.0003
Group B	10.051±4.895	5.251±3.161	0.017

Figure 2.

Group A

Figure 3.

Group A

Figure 4.

Group B

Figure 5.

Group B

In the study, there were no side effects other than localized xerosis at the site of application of zinc and phenytoin paste. Pain, bruising and swelling during withdrawing of intravenous blood were the only side effects observed.

The results of both groups A and B are shown in Figures 2–5.

Discussion

In our study, we determined the efficacy of autologous PRFM in non-healing ulcers. According to the present study, the improvement is 75.99% in the area of the ulcer.

In a similar study by Anirudh Somani and Reena Rai,[11] the improvement was 85.51% which is much higher than the present study.

According to a study by G. Yuvasri,[12] the mean reduction in the area of the ulcer size observed was 86.03%.

In the present study, the improvement in the ulcer size is 47.75% using triple combination paste (zinc oxide, phenytoin, and mupirocin ointment).

In a study by Sehgal et al.[13] zinc oxide and phenytoin paste were used in the treatment of trophic ulcers of leprosy. Complete resolution was seen in 55% of the patients.

In a study by Shafer et al.,[5] granulation tissue was formed in 50–90% of his patients.

In a study by Mukul and Bansal,[14] granulation tissue was observed in all patients within 4 weeks.

In the present study, topical mupirocin ointment is used with zinc and phenytoin in non-infective ulcers as well to avoid infections which cause a delay in the healing process.[15]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.