Diabetic foot ulcers (DFUs) are a leading cause of hospitalization and lower-limb amputation in people with diabetes, and a substantial proportion fail to heal despite good standard care. Autologous platelet-rich plasma (PRP), a concentrate of a patient’s own platelets prepared from a blood sample, has been studied as an adjunct because platelets release growth factors involved in tissue repair, including platelet-derived growth factor, transforming growth factor-beta and vascular endothelial growth factor. This article summarizes what systematic reviews and guidelines published since 2015 say about PRP in DFU care.
Rationale: Why Platelet Concentrates Are Studied in Chronic Wounds
Chronic diabetic wounds are often stalled in the inflammatory phase, with impaired angiogenesis, reduced growth factor signalling and abnormal cellular migration. PRP is applied as a topical gel or injected around the wound in an attempt to supply the missing signals. The approach is biologically plausible, but plausibility is not proof of clinical benefit. Meaningful conclusions depend on controlled trials that measure complete wound closure, time to healing, infection, amputation and safety.
What the Meta-Analyses Report
Cochrane evidence on chronic wounds
The Cochrane review by Martinez-Zapata and colleagues (2016) assessed autologous PRP for chronic wounds across 10 randomized trials involving 442 participants. For diabetic foot ulcers, pooled data from two trials with 189 participants suggested PRP may increase healing (risk ratio 1.22, 95% confidence interval 1.01 to 1.49). However, the authors graded the evidence as low quality, noting that the trials were few, underpowered and generally at high or unclear risk of bias, and called for well-designed, adequately powered studies.
More recent pooled analyses of DFU trials
A later meta-analysis by Su and colleagues (Journal of Wound Care, 2023) pooled 17 randomized trials with 1,303 participants (649 receiving autologous PRP and 654 receiving standard care). Complete healing was more likely with PRP (odds ratio 2.11, 95% CI 1.55 to 2.86), average healing time was roughly 19 days shorter, and adverse events did not differ significantly between groups. The authors concluded that autologous PRP appears to be an effective and safe adjunct.
These results are encouraging, but they should be interpreted with the same caution as the Cochrane findings. Many included trials were small, single-centre, open-label or at risk of performance and detection bias, all of which can inflate apparent treatment effects.
Limitations: Preparation, Protocols and Study Quality
An earlier systematic review by Hirase and colleagues (World Journal of Diabetes, 2018) examined eleven studies including 322 PRP-treated and 126 control patients. It reported faster wound area reduction with PRP (0.68 versus 0.39 cm² per week) and fewer complications (2.5% versus 10.5%), but also documented that five of the eleven studies were lower-level evidence and only one was double-blind. Heterogeneity precluded meta-analysis.
That review highlighted a problem that persists: PRP is not a single standardized product. Centrifugation methods (single or double spin), activators (thrombin, calcium chloride or calcium gluconate), platelet concentrations, application volumes and treatment frequency all vary between studies, and platelet counts are often not reported. Without standardization, it is difficult to know which formulation, if any, drives benefit or to compare results across trials.
Where Guidelines Place PRP
The International Working Group on the Diabetic Foot (IWGDF) 2023 update on interventions to enhance healing of foot ulcers (Chen et al., Diabetes/Metabolism Research and Reviews, 2024) offers a conditional recommendation for the autologous leukocyte, platelet and fibrin patch, to be considered when a wound fails to heal with best standard care and resources are available. The guideline does not make PRP a first-line therapy. It also emphasizes that the certainty of evidence for many adjunctive therapies, although improving, remains low overall, and it calls for higher-quality trials with health-economic analysis.
This framing matters: adjunctive biologic therapies are not substitutes for the foundations of ulcer care, which include pressure offloading, debridement, infection control, assessment of perfusion and glycemic management. Evidence suggests that adjuncts are most reasonable once those fundamentals have been optimized and an ulcer remains stalled.
Clinical Summary
Pooled data from randomized trials suggest that autologous PRP may improve the likelihood and speed of DFU healing, with no clear excess of adverse events. Confidence in these estimates is limited by small trials, risk of bias and wide variation in how PRP is prepared and applied. Current guidance supports considering platelet-derived products only as an adjunct in non-healing wounds under optimized standard care. Large, blinded, standardized trials reporting complete healing, amputation, infection and cost remain the key evidence gap.
References
- Chen P, Vilorio NC, Dhatariya K, et al. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024.
- Su Y-N, Li J, Feng D-H, Lu R-R, Dong G-X, Zhao D-Y. Efficacy and safety of autologous platelet-rich plasma for diabetic foot ulcers: a systematic review and meta-analysis. Journal of Wound Care. 2023;32(12).
- Martinez-Zapata MJ, Marti-Carvajal AJ, Sola I, et al. Autologous platelet-rich plasma for treating chronic wounds. Cochrane Database of Systematic Reviews. 2016.
- Hirase T, Ruff E, Surani S, Ratnani I. Topical application of platelet-rich plasma for diabetic foot ulcers: a systematic review. World Journal of Diabetes. 2018;9(10).
Comments
