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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 27-29

En coup de sabre treated with platelet-rich plasma


Department of Skin and V.D., B.J. Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India

Date of Web Publication1-Dec-2015

Correspondence Address:
Vasudha Abhijeet Belgaumkar
No. 33, Department of Skin and V.D., B.J. Government Medical College and Sassoon General Hospitals, Pune - 411 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WKMP-0110.170747

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  Abstract 

Contour defects such as linear morphea are difficult to treat and can be a cause for great cosmetic and sociopsychological morbidity. The pivotal discovery of platelet-derived growth factors in promoting wound healing, angiogenesis, and tissue remodeling has paved the way for various uses of platelet-rich plasma (PRP). We report a novel indication for this promising therapeutic modality with satisfactory results. A 24-year-old female presented with nonprogressive linear hyperpigmented atrophic lesion over the left supraorbital region and scalp of 15 years duration was diagnosed as linear morphea. She had taken immunosuppressants over the last 3 years with minimal improvement. PRP was obtained with a platelet count up to 2.5 times the baseline count. Calcium chloride (1:9) was added as an activator. About 3 ml of PRP was injected into the linear contour defect every week for a total duration of 12 weeks. The results were corroborated quantitatively by a repeat high frequency focal ultrasound which showed focal minimal irregularity over frontoparietal region of scalp corresponding to bony lesion measuring 0.5 cm × 1.8 cm (original defect of 1.4 cm × 1.8 cm). A remarkable reduction in hyperpigmentation of overlying skin was noted which further enhanced the cosmetic outcome. The effect was sustained until the end of follow-up period of 6 months after the last PRP sitting. No secondary changes or side effects were noted during the entire course of treatment. PRP therapy is safe and effective in the treatment of linear morphea over face and scalp as demonstrated in this case.

Keywords: Contour defects, en coup de sabre, platelet rich plasma


How to cite this article:
Belgaumkar VA, Deshmukh NS, Doshi BR, Mhaske CB. En coup de sabre treated with platelet-rich plasma. Indian J Drugs Dermatol 2015;1:27-9

How to cite this URL:
Belgaumkar VA, Deshmukh NS, Doshi BR, Mhaske CB. En coup de sabre treated with platelet-rich plasma. Indian J Drugs Dermatol [serial online] 2015 [cited 2019 Sep 22];1:27-9. Available from: http://www.ijdd.in/text.asp?2015/1/1/27/170747




  Introduction Top


Linear morphea over scalp (also known as en coup de sabre) is a chronic disorder causing permanent disfiguration of the face. Although multiple treatment approaches have been tried for contour defects, such as fillers,[1] autologous fat graft,[2] dermal skin grafts,[3] botulinum toxin injection,[4] and lasers,[5] with fairly beneficial outcome, these modalities are usually not feasible in resource-limited settings due to lack of affordability or availability. We, successfully, used autologous platelet rich plasma (PRP) to correct contour defect in en coup de sabre in an attempt to devise a cost-effective treatment modality with comparable efficacy.


  Case Report Top


A 24-year-old young, unmarried female presented with nonprogressive linear hyperpigmented atrophic lesion over left supraorbital region extending up to the left frontoparietal area of scalp with focal patch of cicatricial alopecia, since 15 years [Figure 1]. She had taken immunosuppressants (systemic steroids and methotrexate) over the past 3 years which had stabilized the lesion with minimal improvement in the residual contour defect. Clinical diagnosis of linear morphea (en coup de sabre) was confirmed by skin biopsy. A three-dimensional computerized tomography (CT) scan of the head [Figure 2] revealed loss of subcutaneous fat with erosion of outer table of skull over the frontoparietal region and depression over the parietal bone measuring 1.4 cm × 1.8 cm size. High-frequency focal ultrasound demonstrated irregularity over the frontoparietal region of scalp corresponding to the bony lesion measuring 1.4 cm × 1.8 cm.
Figure 1: Linear contour defect extending from left supraorbital margin to scalp.

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Figure 2: Three-dimensional computerized tomography scan images showing bony indentation over frontoparietal region of scalp bone.

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After detailed history, written and informed consent and investigations such as hemogram and HIV-ELISA to exclude any contraindications for the procedure and local ultrasound and CT scan for baseline assessment of the defect, we administered PRP. Ten milliliter of the patient's blood was withdrawn by phlebotomy and divided in citrated vacutainers. It was centrifuged at 800 rpm for 8 min followed by 1200 rpm for 12 min in a digital centrifuge machine (Remi R-8C) at room temperature, resulting in PRP with a platelet count of 2.5–4 times the baseline count. Calcium chloride (1:9)[6] was added as an activator. Strict asepsis was maintained throughout the procedure. A total of 3 ml of PRP was injected into the linear contour defect every week using a sterile insulin syringe. The only concomitant medications administered were broad spectrum sunscreen and topical and systemic antibiotics immediately after the procedure.

The second PRP sitting was followed by a progressive filling up of the defect. More than 80% improvement was evident after 12 injections [Figure 3]. The subjective results were corroborated quantitatively by a repeat high frequency focal ultrasound which showed focal minimal irregularity over frontoparietal region of scalp corresponding to bony lesion measuring 0.5 cm × 1.8 cm, the original defect being 1.4 cm × 1.8 cm size. A remarkable reduction in hyperpigmentation of overlying skin was noted which further augmented the cosmetic outcome. The effect was sustained until the end of follow-up period of 6 months after the last PRP sitting. No secondary changes or side effects were noted during the entire course of treatment. In order to further uphold the effect, the patient is now being administered maintenance injections of 0.5–1 ml of PRP at an empirical interval of 6 months. After two such sessions, we plan to discontinue the injection and monitor the longevity of the effects.
Figure 3: Postplatelet-rich plasma image showing filling up of contour defect and reduction in hyperpigmentation over forehead due to linear morphea.

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  Discussion Top


Autologous PRP is a concentration of platelets in a small volume of patients' own plasma containing nine main growth factors proved to be degranulating to initiate collagen remodeling.[6] These include transforming growth factors β1 and 2, platelet-derived growth factors-AA, AB, and BB, vascular endothelial growth factors-A and C, insulin-like growth factor-1 and epidermal growth factor. In addition, PRP also contains fibronectin, vitronectin, fibrinogen, osteocalcin, and osteonectin which are known to act as cell adhesion molecules and as a matrix for cellular processes. The active secretion of these factors is triggered by clotting process of blood and can be activated by adding thrombin or calcium chloride. Although initial burst occurs within 10 min with more than 95% of presynthesized growth factors secreted within 1 h, platelets continue to synthesize and secrete additional proteins until their life span (of up to 10 days). PRP also has a mitogenic effect on endothelium and other mesenchymal stem cells such as adipocytes and dermal fibroblasts. This stimulatory effect of platelets on collagen remodeling and fibroblasts warrants its use in the correction of small contour defects.

Bendinelli et al.[7] have reported anti-inflammatory effect by reduction of COX 2 and CXCR4 gene expression. All these mechanisms explain the efficacy of PRP in indications such as acne, scars, chronic ulcers, and alopecia and as a corollary, disfiguring contour defects such as morphea. Jin et al. demonstrated the increased survival of fat grafts and fillers when harvested in freshly prepared autologous PRP.[8]

Ortega and Sastoque [9] successfully used bovine tendon collagen, glycosaminoglycans, and fat grafts harvested in PRP to correct contour defects in Parry Romberg syndrome.

Thus, although the use of PRP as an adjuvant to other natural and synthetic fillers has been reported in previous studies, its use as monotherapy in morphea so far is hitherto unreported.

Although monotherapy of small contour defects with autologous PRP requires more number of sittings as compared to its use in adjunction with fillers and fat grafts, it can produce similar long-term results. Our case of en coup de sabre that was treated with PRP monotherapy required a total of 12 weekly sittings and is currently on maintenance "touch up" injections of PRP every 6 months.

In comparison, dermal fillers are far more costly than PRP. They too may require repeated sessions depending upon the type of filler used (the cost of treatment being approximately proportional to the life of the filler). Hence, in a resource-limited setting or patients with limited affordability, PRP monotherapy is a cost effective substitute especially for those who cannot afford dermal fillers or the procedural cost of fat or dermal grafts. The advantages of using PRP alone as against its combination with fat/dermal grafts are its simplicity, minimal cost, and low-risk potential of the procedure.

We utilized a basic centrifuge machine (Remi R-8C) and the basic infrastructure that was available in our tertiary care hospital. On the other hand, use of sophisticated and advanced equipment such as commercially available PRP kits or a cryo-centrifuge would probably hasten and enhance the treatment outcome attributable to attainment of higher platelet counts.

To conclude, though there are various options to correct contour defects such as lasers, fillers, autologous fat grafts, and dermal grafts with good and long lasting outcomes, their use may be limited by the cost and feasibility. In this era of cosmetology, autologous PRP has the potential to become a successful and cost-effective first-line therapy with equivalent efficacy and longevity in the treatment of contour defects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Weiss RA, Weiss MA, Beasley KL, Munavalli G. Autologous cultured fibroblast injection for facial contour deformities: A prospective, placebo-controlled, Phase III clinical trial. Dermatol Surg 2007;33:263-8.  Back to cited text no. 1
    
2.
Lau YS, Offer GJ. Treatment of soft tissue contour defects by a combination of surgical subcision with a Beaver tympanoplasty blade and autologous fat grafting. Aesthetic Plast Surg 2010;34:406-7.  Back to cited text no. 2
[PUBMED]    
3.
Leaf N, Zarem HA. Correction of contour defects of the face with dermal and dermal-fat grafts. Arch Surg 1972;105:715-9.  Back to cited text no. 3
[PUBMED]    
4.
Nanda S, Bansal S. Upper face rejuvenation using botulinum toxin and hyaluronic acid fillers. Indian J Dermatol Venereol Leprol 2013;79:32-40.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Goodman G. Laser-assisted dermal grafting for the correction of cutaneous contour defects. Dermatol Surg 1997;23:95-9.  Back to cited text no. 5
[PUBMED]    
6.
Arshdeep, Kumaran MS. Platelet-rich plasma in dermatology: Boon or a bane? Indian J Dermatol Venereol Leprol 2014;80:5-14.  Back to cited text no. 6
    
7.
Bendinelli P, Matteucci E, Dogliotti G, Corsi MM, Banfi G, Maroni P, et al. Molecular basis of anti-inflammatory action of platelet-rich plasma on human chondrocytes: Mechanisms of NF-κB inhibition via HGF. J Cell Physiol 2010;225:757-66.  Back to cited text no. 7
    
8.
Jin R, Zhang L, Zhang YG. Does platelet-rich plasma enhance the survival of grafted fat? An update review. Int J Clin Exp Med 2013;6:252-8.  Back to cited text no. 8
    
9.
Ortega VG, Sastoque D. New and successful technique for the management of Parry-Romberg syndrome's soft tissue atrophy. J Craniofac Surg 2015;26:e507-10.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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