L-PRF in chronic wounds
Introduction
The primary objective of wound care is to achieve wound closure as promptly as possible, thereby reducing the risk of complications and enhancing patients' quality of life. Four crucial factors must be systematically addressed to promote wound healing: (a) removal of nonviable or necrotic tissue, foreign bodies, exudate, and/or biofilm, (b) identification of the wound's aetiology, controlling infection, and managing inflammation, (c) application of an adequate dressing to regulate exudate levels and maintain moisture balance, and (d) assessment of the wound edge, which reflects the progress of wound healing and confirms the efficacy of the applied therapy (Harries et al. 2016, Schultz et al. 2003).
L-PRF membranes exhibit several critical characteristics for wound healing, including barrier function, antibacterial and analgesic activities, and the release of growth factors that promote tissue regeneration and neo-vasculogenesis. L-PRF has shown significant adjunctive benefits in the treatment of chronic skin wounds, such as diabetic foot ulcers, venous leg ulcers, pressure ulcers, complex wounds, and leprosy ulcers (Hansen’s Disease). L-PRF accelerates wound closure, improves patient-reported outcomes by reducing pain and minimizing the need for analgesics, and enhances patients' quality of life, productivity, and life expectancy. Additionally, L-PRF significantly reduces the treatment costs for patients and public health systems (Pinto et al. 2025).
Protocol: step by step
It is essential to begin with a comprehensive evaluation of a patient's medical condition and optimize their health status by verifying underlying systemic conditions, medication, nutritional status, ... before initiating therapy. Moreover, any wound infection should be managed prior to commencing L-PRF treatment.
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gently clean the wound through irrigation with a standard saline solution or wound cleanser to remove all exudate,
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disinfect the wound and surrounding area (e.g., Isobetadine),
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perform a debridement of the wound to remove necrotic material, crusts, sloughed, and devitalized tissue from the wound, including tunnels and/or cavities; avoid a profound debridement due to its potential negative impact,
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activate the wound by creating bleeding points,
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eventually apply a liquid film-forming acrylate (e.g., Cavilon spray) around the wound to prevent maceration, especially in case of exudating wounds,
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inject L-PRF exudate into the wound periphery and, if possible, directly into the wound to stimulate tissue regeneration,
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apply L-PRF membranes over the entire wound,
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cover the wound and wound edges (at least 2 cm) with a "non-adhering" perforated primary dressing (e.g., Adaptic touch, Mepitel One); this dressing should (i) be conformable to the wound bed, (ii) stay in place over the wear time, (iii) transmit wound exudate to the secondary dressing, and (iv) cause minimal trauma upon removal,
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eventually cover the primary dressing and wound periphery with a plastic film to ensure a moist environment, protect the L-PRF membranes from dehydration, and act as a barrier to external contaminants,
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apply a dry dressing to absorb wound exudate; this dressing can be changed as needed (e.g., to absorb additional exudate and avoid unpleasant odors) without disturbing the underlying wound dressing,
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finally, a 3rd layer must be applied (e.g., Mefix or a plastic gauze bandage) to secure the previous dressings and protect the wound.
step-by-step flow charts
This treatment should be repeated every week (eventually every second week at the end of the therapy). Each session should follow the same protocol, with the exception of debridement, which should not be repeated. However, any loose L-PRF membranes, necrotic tissue, microbial material, sloughed tissue, and crust should be removed. L-PRF membranes that are firmly attached to the wound surface or those that are becoming granulation tissue should not be removed! Wound-type-specific recommendations are included at the end of this webpage (Important).
"detailed" step-by-step protocol with product information
Video: L-PRF treatment of non-responding diabetic ulcer.
Interim treatment of a large, non-responsive diabetic foot ulcer with L-PRF membranes. The video was taken during the first week follow-up. Nearly all membranes were well integrated. A superficial cleaning was performed, followed by an injection of L-PRF exudate. New L-PRF membranes were then applied, along with a new wound dressing.
A. Diabetic foot ulcers (DFU)
(d = day, w = week, m = month, y = year)
1: Large non-responsing diabetic foot ulcer.
d 0: a large and deep DFU not responding to surgical treatment and debridement.
d 0: clinical view after wound cleaning and debridement.
d 0: complete wound coverage with 16 L-PRF membranes.
d 7: image just before removal of the plastic film and the "non-adhering" knitted primary dressing.
d 7: after removal of dead tissue and non-adhering L-PRF membranes, L-PRF exudate is injected.
Complete wound closure was obtained after 8 weeks.
y 1: follow-up visit with nice healing and no ulcer recurrence.
Courtesy: Diego Pinto
2: Non-healing wound following big toe amputation in diabetic patient.
d 0: non-healing wound after toe amputation with bone and tendon exposure, initially scheduled for full foot amputation; L-PRF was chosen as the last option.
d 7: clinical view 1 w after the first application of L-PRF membranes showing the formation of granulation tissue.
w 12: complete wound resolution and no recurrence during the next 5 years.
5 y: RX confirming a good bone healing (no longer signs of osteomyelitis).
Courtesy: Nelson Pinto
3: Infected wound from a diabetic patient who stepped in a contaminated nail.
d 0: conventional treatment and surgical debridement failed, an amputation was scheduled.
w 3: the patient refused an amputation and opted for an L-PRF therapy; slight improvement after 3 applications of L-PRF membranes.
w 8: a complete wound resolution was achieved.
Courtesy: Yelka Zamora
4: Chronic diabetic wound.
d 0: DFU with tendon exposure, osteomyelitis and fistula through the entire foot.
d 0: RX showing clear signs of osteomyelitis.
y 5: follow-up picture of the healing; closure was obtained after 7 weekly applications of L-PRF membranes; no recurrence of the ulcer afterwards.
Courtesy: Nelson Pinto
y 5: RX radiograph indicating the resolution of the osteomyelitis.
B. Venous leg ulcer (VLU).
1: Recalcitrant VLU (22 years without significant improvement).
d 0: 12 cm long wound which did not respond to "advanced" wound care.
Courtesy: Nelson Pinto
w 4: full closure could be achieved, and no recurrence was observed during 5 years follow-up.
2: Recalcitrant VLU (16 years without significant improvement).
d 0: clinical image at 1st L-PRF treatment.
d 0: 8 L-PRF membranes covered the entire wound area.
d 0: application of a "non-adhering" knitted primary dressing and a plastic film as protection against dehydration.
w 16: Complete wound resolution.
w 18: stable situation.
y 2: no recurrence over a 2-y period.
Courtesy: Diego Pinto
3: Large non-healing VLU, 12 y recalcitrant to advanced therapy.
d 0: initial lesion with major impact on patient's well-being.
d 7: clinical image taken one week after the initial application of L-PRF membranes. Granulation tissue has begun to appear, and L-PRF membranes were applied only to areas with poor granulation tissue.
w 8: significant reduction in wound size.
y 1: wound closure after 3 months, the leg remained healthy as seen at the 1-year follow-up, without any recurrence.
Courtesy: Yelka Zamora
C. Complex chronic ulcers with multifactorial etiology (CU).
1: 2y non-responding complex wound (diabetes, venous, arterial complications)
This patient presented with an initial 10 cm wound on the lower leg, necessitating the use of a wheelchair. Although amputation was suggested, the patient refused. The wound was finally treated with L-PRF membranes. The clinical images demonstrate gradual healing at weeks 3 and 6, and at month 4, when small perforations were made in the bone.
Courtesy: Nelson Pinto
Additional clinical views at m 5, m 7 (when the patient could walk again). At m 10 nearly full wound coverage was reached. Follow-up pictures after y 1 and y 3.5 show a nice healing, without wound recurrence.
2: Chronic ischemia after the amputation of the big toe and neighbouring toe.
d 0: the complex wound after cleaning and careful debridement.
d 0: application of 8 L-PRF clots, which will be compressed in situ.
Courtesy: Enrico Rescigno
w 10: nearly complete wound closure was achieved.
D. Leprosy wounds (LU).
1: Trophic leprosy ulcer not responding to standard therapy.
Courtesy: Sushil Koirala
Closure of a trophic leprosy ulcer via the weekly application of L-PRF membranes, with the initial condition and the healing after w 5, w 8, and complete closure at w 9.
2: Trophic leprosy ulcer not responding to standard therapy.
Courtesy: Sushil Koirala
Clinical view of a trophic leprosy ulcer after debridement, followed by the application of L-PRF membranes, resulting in a complete wound closure after 8 weeks.
3: Trophic leprosy ulcer not responding to standard therapy for 7 years.
Clinical view of a trophic leprosy ulcer after debridement to remove all dead tissue, and the progressive healing after the weekly application of L-PRF membranes with pictures after w 3, w 5, and complete closure of the wound after 8 w.
Courtesy: Sushil Koirala
E. Burn
1: Severe burn on lower leg.
The healing of a second-degree burn with hot water. Standard therapy, over a month time, failed to heal the wound (mid upper picture) and an autograft had been proposed. 2 L-PRF membranes were placed over the wound bed. 5 days later, the wound showed moderate exudate and a significant decrease in pain. L-PRF membranes were reapplied and 7 days later the wound size had reduced to 2x3 cm². After an additional L-PRF treatments the wound was completely epithelialized with very thin and fragile skin. It was covered with dressings to protect it, and 10 days later, the wound was completely epithelialized with firm skin.
Courtesy: Catalina Carvajal Contreras
2: Severe burn on four fingers.
A dental technician burned her fingers while making a crown in wax. The burn wounds were treated with L-PRF. It was important for her that scar formation was minimized. The healing process went very well, as seen in the photo taken after eight weeks. Scar formation could be prevented, and she retained perfect flexibility in her hands, allowing her to continue her profession without any hindrance.
Courtesy: Nelson Pinto
F. Frostbite.
An athletic individual experienced an accident during a winter sports holiday, resulting in the freezing and mummification of the right buttock (gluteus), all fingers on the right hand, and several fingers on the left hand. The wound on the buttock healed quickly following the application of L-PRF membranes. For the fingers on the right hand, a complete amputation was initially proposed after mummification. However, the patient refused this option and opted to have the fingers treated with L-PRF instead. During this therapy, it was crucial to keep the fingers moist to maintain optimal conditions for the exposed bone and prevent necrosis.
Following L-PRF therapy, two phalanges in four fingers were surgically removed, and the wounds were closed using the regenerated tissues. The patient received L-PRF treatment for 18 weeks. The final photo shows the patient engaging in all beloved sports again, without the need for any prosthesis.
Courtesy: Catalina Carvajal Contreras
Data:
Most relevant clinical trials on the impact of L-PRF on chronic wounds
Abbreviations: Study type: RCT = randomized controlled trial, Ps = prospective case series, CCS = case control study; d = day, w = week, m = month, y = year. Wound info: VLU = venous leg ulcer, DFU = diabetic foot ulcer, DHU = diabetic hand ulcer, PU = pressure ulcer, LU= leprosy ulcer/Hansen’s disease, Neu = neuropathic, TrU = trophic wound, Scu sickle cell ulcer, Compl = complex wound, TU = trauma ulcer, inf = infection, post-sur = post-surgery wound breakdown, x̄ = statistical mean, NR = not reported. Intervention: Pr = prior to start L-PRF treatment, R/ = treatment: (debridement often only once at start therapy), adv dress = advanced dressing, n-ad dress= non-adherent dressing, C = control, T = test, L-PRF m = L-PRF membrane, mF = face part of membrane / cl = clot / ex = exudate; * often compressed in situ, rhEGF = recombinant human epidermal growth factor gel, HA = hyaluronic acid. Outcome: AE = adverse events, wound closure: CR = complete resolution, discont’d = discontinued, PROMs: patient-reported outcome measures, > = increased, < = decreased.
Conclusion
These papers illustrate the beneficial effect of L-PRF in the treatment of chronic skin wounds, shortening the time to complete wound closure, and improving patient-reported outcome measures (including reducing pain and minimizing the need for analgesics). Also, in other demanding wounds, L- PRF facilitates healing (for details, see Pinto et al. 2025).
Important notice
General observations in reviewed papers
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In most patients, the ulcer had been present for weeks, months, or even years and had not responded to standard or conventional therapy. However, nearly all these chronic wounds achieved complete resolution following the use of L-PRF membranes, typically applied weekly over a period of 2 to 10 sessions.
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Only one adverse event has been reported. This occurred in a patient with comorbidities and a skin allergy, who initially experienced improvement but later worsened, leading to the discontinuation of the L-PRF therapy.
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The healing time is directly proportional to the original wound size; larger wounds require more applications of L-PRF membranes.
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There is no correlation between the duration of the wound prior to the L-PRF treatment and the time to complete resolution after L-PRF therapy.
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It is crucial to begin with a thorough evaluation of a patient's medical condition and to improve/optimize their general health status (including an assessment of underlying systemic conditions, medication, nutritional status, etc.) before initiating therapy. Without this essential step, a successful outcome is jeopardized, and ulcer recurrence is more likely.
This figure illustrates the healing sequence for DFU and VLU (from Pinto et al. 2018).
Reduction in wound area (expressed in cm²) over time are given for: DFUs (9 patients, 10 wounds) and VLUs (subdivided into ≤10 cm² (16 patients, 17 wounds) and larger >10 cm² (14 patients, 15 wounds) initial wounds). Patient ML started with an initial wound area of 74.5 cm²; however, to better visualize the other wounds, the y-axis was cut off at 64 cm².
L-PRF was applied weekly, and photographs were taken at intervals to analyse changes in wound area (each mark represents a wound size analysis). For patients who did not reach full wound closure, the reasons were noted (Δ: indicates interruption due to financial reasons, Ο indicates relocation to a different area/hospital, or ◊ indicates no information available).
Wound-type-specific recommendations during active therapy
The treatment strategy for diabetic foot ulcers (DFU), venous leg ulcers (VLU), pressure ulcers (PU), complex ulcers (CU) and leprosy plantar ulcers (LU) includes a number of similar steps, but also some wound-type-specific steps.
DFU/PU/CU:
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Patients should avoid pressure and movement on the wound site, particularly during the first 3 days after treatment. In case of foot deformities (e.g., Charcot's foot), the patient should wear special shoes or completely avoid stepping on the affected foot for at least a week.
VLU:
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Always apply an elastic bandage as standard compression therapy.
PU:
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Patients should avoid pressure and movement on the wound site, especially during the first 3 days after treatment.
LU:
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LU generally generally have hard callus formation around the wound periphery. Therefore, it is necessary to remove such hard callus with a surgical blade and create bleeding points if possible. Superficial debridement should then be performed to remove necrotic material, eschar, devitalized tissue, or any other type of bioburden from the wound (providing some bleeding points), including wounds with tunnels and/or cavities, to promote wound healing. Profound debridement should be avoided due to its negative impact!
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Cover the applied L-PRF membranes with a non-adhering knitted primary dressing, followed by a dry dressing to capture the typical exudate of the wound, which usually increases during the first application.
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The dry dressing can be changed as needed (e.g., to absorb additional exudate, to avoid unpleasant odors) without disturbing the primary dressing underneath.
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Patients should avoid pressure and movement on the wound site, especially during the first 3 days, and should wear special shoes or completely avoid stepping on the affected foot for at least a week. Additionally, patients should protect other areas of the foot from dryness and apply suitable moisturizers (e.g., paraffin wax dermal ointment).
Aftercare
All wounds:
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Inform the patient about measures to prevent ulcer recurrence!
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Advice the patient to regularly apply a dermal ointment on the regenerated skin to keep it soft and lubricated.
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Recommend protecting the area from direct sun exposure and always using sunscreen.
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Emphasize the importance of protecting the healed site from scratches and external shocks!
DFU/CU/VLU:
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Inform the patient about the importance of adhering to correct medication protocols.
VLU:
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Instruct the patient to use compression therapy daily.
PU:
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Advise the patient to prevent pressure points on the healed site.
Wound infection
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All chronic wounds are contaminated with various bacteria. However, wound infections during the L-PRF treatment are rare! When applying the L-PRF membranes, ensure that the face of the membranes (the red part that was initially in contact with the red blood cells) is positioned towards the suspected area. This orientation allows the leukocytes in the face area to more effectively reach the infection.
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Upon observing the first signs of infection, a more thorough disinfection should be performed. For instance, apply a gauze embedded with/soaked in an antimicrobial solution (e.g., iodine or dialkyl carbamoyl chloride) to the infected area and leave it for several minutes.
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Antibiotic therapy is not recommended unless a moderate or severe infection is present. Specific systemic antibiotics should be administered concomitantly with the L-PRF therapy, based on the results of a bacterial culture!
for more information see
Interesting references
Several videos and/or cases on this webpage are discussed more in detail in the following book: Quirynen M & Pinto N 2022. Leukocyte- and Platelet-Rich Fibrin in Oral Regenerative Procedures. Quintessence Publishing;
ISBN: 978-1-78698-105-9