PRPIntroductionPlatelet rich plasma (PRP) is rapidly rising as a source of growth factors to help in many clinical situations. Only an absolute basic few principles are reviewed here.DisclaimersThe big disclaimer in this walk through of PRP today is that it is ultra minimal.There are distributors and scientific reviews that are much more comprehensive than this. But this should give you a good overview to start out on understanding a safe treatment option available to you instead of so many dangerous surgeries and dirty medicines for so many things.DiscussionPRP, platelet rich plasma from you, contains platelets. Platelets are little sacks of growth factors, similar to cells, but contain no nuclear material - - no nuclei at all.So if there is no nucleus in a platelet, it contains all of these growth factors, but doesn’t know exactly what to do with them. The platelet instinctively goes to areas of inflammation and wounds to help heal wounds and resolve inflammation.But it must get instructions there. Cells that are healthy locally can give it instructions. The wound has ailing cells that can give it instructions. And stem cells are probably the best “computers” in the body that can give platelets instructions.So I guess that’s one of the big take-home’s: PRP works best if there is an abundance of high-quality stem cells nearby. Conversely, PRP doesn’t work well if there’s not many stem cells. One situation in which there are not many stem cells is aging. As we age, our stem cell numbers and quality decreases. So the extrapolation is, you guessed it: PRP does not work well in the elderly.So, if an elderly person is considering PRP for its many indications, many of which are reviewed below (and I know that’s why you’re probably reading this) (so, we’re almost there!), then that elderly person might higher prioritize getting some stem cells on board first.Another situation where PRP won’t work by itself no matter how many times you try it (John Wall) is in the joint which is highly nonvascular, so often times doesn’t contain many stem cells. Such an athlete might consider getting stem cells first which will last in their body 30 months including deployments directly into a knee… And then administer some PRP if you want. But many scientific journals are pointing to the fact that all things like knees need is stem cells alone without the PRP. But that’s another subject.So I’ll repeat this first big principal and all its repercussions: PRP requires stem cells to work. PRP will work better in young people than elderly. PRP will work better in people who have received stem cells recently. PRP will work better in people who receive stem cells concurrently, although many argue that the stem cells alone would suffice in that setting. PRP won’t work in avascular areas where there are not many stem cells like joints.PRP is obtained using PRP kits provided by many distributors in the US and Canada. PRP is extracted from venous blood - - just a regular blood draw folks. So when we talk about giving you PRP, we are giving you back platelets we pulled out of you, same day, usually same hour.Different PRP kits very in quality, and I’m not saying it isn’t always high-quality and safe. It pretty much is. PRP kits vary in how much white cells that they contain as if it was a strength, and I’m not saying that it always isn’t. And PRP varies in platelet concentration. And PRP kits vary in terms of whether they are activated or not.A source of some confusion to the novice, PRP also varies in activated versus non-activated. This is a much more important distinction you must understand - - and it’s easy. Activated PRP (activated for their prime function to help a damaged area of tissue) means that the platelets have been exposed to calcium salts such as in an active wound where cells are exploding and dumping out calcium salts. If platelets are exposed to calcium, they start working, and quickly - - they start getting sticky, leading to the formation of a fibrin clot - - and that’s what a wound needs. The other thing that happens when the platelet start getting sticky and Jell-O like instead of free-flowing is that they stay around. That is, they don’t migrate off.So. Activation when it comes to PRP means formation of fiber matrix. So some people would rather not worry about that fiber matrix with the PRP they are using. And they use other scaffolding or matrix sources, some of them allogenic, a term that literally means from a non-homologous source, i.e., from someone else.Some clinical situations have enough inflammation and activity from cell death that the platelets will be activated when they get into the body part. In those situations, they don’t need to be activated. The body will activate them. What do you like it or not, that activated PRP will stick around in that area.In other clinical situations, there is no cell break down, and you want the PRP to stick around. So you have to activate that PRP before administering it. Usually exposing it to a calcium salt like calcium chloride or cost include gluconate activates the PRP. The PRP is deployed; the PRP sticks around that area.And yet other clinical situations, there is no cell break down and you DON’T want the PRP to stick around locally. You were interested it and it defusing a little further away. Growth factors to encourage hair regeneration require this.So two more big principles. 1. PRP should be activated to keep locally (not for hair) (not for the P shot) (not for the O shot). In all of the situations, you don’t want to keep the PRP local. You want it to spread to the surrounding tissues. 2. If there is inflammation, you will want the PRP to stick around. But the bar is inflammation will activate the PRP, so it doesn’t need to be activated.Whether or not to activate the PRP that’s about to be used as important because as soon as you activated before deployment, you have a ticking clock. The stuff thickens very quickly, and it makes it harder and harder to administer by the minute after activation has been done outside the body in those situations that require it.And there is another distinguishing feature of PRP types. You can have a high density concentration, or you can have a low density concentration of platelets. Depending on how the PRP is mixed. Not all that significant as far as I can tell. After all, when you get your blood drawn for your PRP, your quantity of platelets is going to vary day to day depending on so many factors. Luck of the draw really. Ha. Pun intended.Indications for PRPJoints, Tendons, LigamentsHair, Skin problemsSexual function, so for the Penis it’s the P shot. The O shot in womenInflamed joints, arthritis, the situations benefit from PRP. But many argue that when it comes to joints, all you really need is stem cells. I’m going defer discussion on this.Hair. You might think with no inflammation or active wound, we might want to activate the PRP before deployment. But, no. The PRP should not be activated and that’s so it can spread around. It will activate in the body soon enough. The deployment is extremely superficial, just a couple of millimeters. And it’s leading to great things. Again, stem cells will be required for the PRP to help a man or woman regenerate hair or prevent hair loss. So, strongly consider investing in stem cells first, then PRP second if you are trying to regenerate tissue is the alopecia arena.The P shot with PRP, done in conjunction with shockwave therapy, is dramatically helping erectile dysfunction, as well as Peyronie’s disease and other more rare indications. The P shot, which is actually several shots along the shaft and glans of the penis, in conjunction with an increase vascularity treated with shockwave therapy, is leading to maximizing penile function not only severely impaired men, but even in fairly normal men. The results have been spectacular. We are just beginning to see the safe care effects in this strong indication for PRP.The “O” shot with PRP, which is actually two shots, one to the Skinners gland, and one elsewhere (different discussion on that) is helping with dyspareunia and lichen sclerosis, two serious conditions which affect women’s sexual health. But it is also helping much more healthy women increase general pubis color (consistent with increasing blood vessels there), thus leading to increased sensitivity during intercourse. So... Exciting advances in both of these arenas, in the highly unfortunate clinically ill, as well as the nearly healthy trying to optimize or improve an already fairly healthy sexual system. PRP is truly helping a lot of couples.ConclusionSo we begin to see a general principle that recurs again and again in all considerations of regenerative medicine. It is that you need growth factors from things like PRP, and you need guiding computer-like agents - - things like stem cells, and you need a matrix or scaffolding on which regeneration (some still call it healing, but that’s probably not entirely correct) can occur.PRP, so rich in platelets required for the traditional clotting of wounds, is going to be filled with growth factors. That’s really all they bring to the table. Pretty simple.And if you want your PRP growth factors to remain in the area of the deployment sustained for days instead of hours, you think of activating the PRP before deployment. If you in contrast prefer that the PRP defuse to the surrounding tissues for your particular application like hair maintenance and regeneration, you avoid pre-activation, so as to allow PRP to diffuse, and then the fiber matrix is created by the body later when it activates the PRP in a slower fashion allowing spread to more remote areas from the site of deployment.Stay well,David Allingham, MD