Diabetic foot ulcer (DFU) is one of the most serious complications of diabetes, characterised by high mortality and recurrence rates (Armstrong et al, 2023). Studies indicate that the 5-year mortality rate of patients with DFUs is approximately 30%, while those undergoing major amputation have a 5-year mortality rate exceeding 70%. Additionally, the recurrence rate of DFU is about 30% within 1 year and 70–80% within 5 years (Armstrong et al, 2017). Regenerative medicine, which integrates engineering, life sciences and medicine, aims to repair or replace damaged tissues, promote regeneration, and sustainably address chronic injuries (Li et al, 2021). Among these, platelets and their derivatives, such as platelet-rich plasma (PRP), platelet-rich fibrin (PRF), concentrated growth factors (CGF), platelet-derived exosomes, and platelet membrane vesicles, have attracted widespread attention as natural biomaterials for wound healing and tissue regeneration. In the 2023 updated guidelines of the International Working Group on the Diabetic Foot, platelets and their derivatives are recommended as adjunctive therapies to promote DFU healing (Schaper et al, 2024). This review summarises the preparation techniques, mechanisms of action, and clinical applications of platelet-derived products in DFU management.
Preparation techniques
Currently, the preparation of PRP lacks a standardised protocol. Clinically, the two-step centrifugation method is commonly used: whole blood is drawn into sterile tubes containing anticoagulant, followed by an initial centrifugation to separate blood components. A second centrifugation step further concentrates the platelets, ultimately yielding an upper layer of platelet-poor plasma (PPP) and a lower layer of PRP (Stevens and Khetarpal, 2018). In contrast, the preparation of PRF is simpler and does not require anticoagulants or activators. Immediately after blood collection, a single centrifugation step separates the sample into three layers: the upper PPP, the middle PRF layer, and the bottom red blood cell layer (Miron et al, 2024). CGF is produced using an advanced variable-speed centrifugation technique, also without anticoagulants. This process utilises different centrifugation speeds and durations to optimise the concentration of growth factors. The resulting layers are: upper serum, middle CGF enriched with leukocytes, stem cells, and polymerised fibrin, and a bottom red blood cell layer (Chen and Jiang, 2020). The preparation of platelet-derived exosomes and membrane vesicles involves activating PRP with agents such as thrombin or collagen to stimulate the release of vesicles and exosomes from platelets. Membrane vesicles are collected by high- and ultra-speed centrifugation, washed with phosphate-buffered saline, and resuspended for storage. Exosome isolation requires even higher centrifugation speeds and more refined processing techniques (Spakova et al, 2021).
Applications of platelet derivatives in DFU management
PRP in DFU management
PRP has received extensive clinical support in the management of DFUs. Studies have shown that PRP can significantly reduce wound area, accelerate healing and relieve pain (Izzo et al, 2023; Zhao et al, 2025). Some reports indicate a complete healing rate of up to 95% in PRP-treated groups, significantly outperforming conventional treatments, especially in women and patients over 55 years of age (Ullah et al, 2023). Moreover, combining PRP with negative pressure wound therapy (Wang et al, 2022) or traditional Chinese medicine (Du et al, 2022) has shown synergistic effects in accelerating wound closure. The authors’ team compared allogeneic and autologous PRP, finding both significantly shortened healing time with no notable adverse reactions, providing a viable alternative when autologous PRP is insufficient (He et al, 2020). However, the efficacy of PRP may be influenced by factors such as obesity, smoking, diabetes duration over 20 years, and moderate-to-severe renal insufficiency (Kanber et al, 2023). Notably, PRP has also demonstrated promising healing and limb-salvage effects in DFU patients complicated by necrotising fasciitis, gas gangrene and osteomyelitis (Deng et al, 2016; Jiang et al, 2020).
Despite its effectiveness, PRP has limitations, including the rapid degradation of growth factors, leading to insufficient sustained release. Additionally, the use of anticoagulants and heterologous thrombin may trigger immune reactions (Strauss et al, 2018), and the fibrinogen polymer network can impact cytokine retention and cellular activity (Marchetti et al, 2020). To address these challenges, second-generation PRF and third-generation CGF were developed, showing enhanced potential in DFU wound management.
PRF in DFU management
Choukroun introduced PRF as a second-generation platelet concentrate (Choukroun et al, 2006). Unlike PRP, PRF preparation does not require any additives and involves a single centrifugation step, making it simple and safe. A previous study has shown that leukocyte- and platelet-rich fibrin (L-PRF) effectively promotes DFU healing, increases overall cure rates, shortens the preparation time for skin grafts, improves graft acceptance, and reduces postoperative complications and amputation rates (Wang et al, 2024). PRF is also beneficial for chronic wounds complicated by osteomyelitis (Crisci et al, 2023) and has shown significant efficacy in treating refractory venous ulcers, pressure ulcers, and complex chronic wounds (Pinto et al, 2018). In combination therapies, PRF with oral vitamins E and C has been shown to enhance healing by reducing oxidative stress (Yarahmadi et al, 2021). When combined with hyaluronic acid, PRF enhances angiogenesis and reduces inflammation, promoting granulation tissue formation and significantly improving healing outcomes compared to PRF alone (Kartika et al, 2021).
CGF in DFU management
In 2011, the concept of CGF was developed based on PRF, classifying it as a third-generation platelet concentrate (Rodella et al, 2011). Prepared using additive-free, variable-speed centrifugation, CGF provides higher concentrations of growth factors and can be formulated as gel, liquid, or loose gel to meet different clinical needs (Zhang et al, 2021). Studies have demonstrated that CGF significantly promotes granulation tissue formation and re-epithelialisation in chronic wounds, facilitating regeneration of both superficial and deep wounds (Kao, 2020). A multicentre randomised controlled trial further confirmed CGF’s efficacy in healing mixed ulcers caused by chronic venous insufficiency and peripheral artery disease, with advantages in healing time and pain relief (Amato et al, 2019). Although CGF has been mainly used in dentistry and cosmetic surgery, the authors’ clinical research suggests CGF is also effective in treating refractory DFU and osteomyelitis, improving limb-salvage rates. Moreover, CGF has shown promising regenerative effects in bone defects, arthritis (Malcangi et al, 2023), and nerve injury repair (Chen and Jiang, 2020), with notable capabilities in tissue regeneration and collagen production. In conclusion, CGF represents a promising new therapeutic approach for promoting wound healing and limb preservation in DFU, offering new avenues for comprehensive DFU management.
The role and mechanisms of PRP-derived exosomes in DFUs
PRP-derived exosomes (PRP-Exos) contain a variety of bioactive molecules, including proteins, mRNA, and microRNAs. Our research team found that PRP-Exos activated by calcium gluconate/thrombin significantly enhance endothelial cell proliferation and migration by activating the AKT/ERK signalling pathway, thereby accelerating wound healing (Rui et al, 2021). We also demonstrated that sphingosine-1-phosphate (S1P) within PRP-Exos binds to its receptor on endothelial cells, activating the AKT/FN1 pathway and promoting angiogenesis and tissue repair in diabetic wounds (Chen et al, 2023).
Recent studies have corroborated our findings, showing that PRP-Exos stimulate fibroblast and endothelial cell proliferation and migration, while modulating lncRNA MALAT1 and reactive oxygen species (ROS)-related pathways to enhance DFU healing (Chen et al, 2023; Cao et al, 2023; Guo et al, 2017). Our latest research identified that miRNA-26b-5p within PRP-Exos targets MMP-8, reducing neutrophil infiltration and NET formation, thus promoting wound healing and highlighting the crucial role of miR-26b-5p in PRP-Exos-mediated diabetic wound repair (Rui et al, 2024). Moreover, bioengineered hydrogels incorporating PRP-Exos with various drugs and materials have demonstrated superior efficacy over single-agent treatments in animal models, significantly enhancing wound closure (Bakadia et al, 2023). However, PRP-Exos isolation and purification remain complex and time-consuming, with no established large-scale extraction protocols. Most studies are limited to in vitro and animal models, necessitating further clinical validation. A recent study provided preliminary evidence of the safety and efficacy of PRP-Exos in human chronic wound healing, paving the way for future clinical translation (Johnson et al, 2023).
Role of platelet membrane vesicles in DFU management
Platelet membrane vesicles exhibit immune-evasive properties due to surface expression of molecules, such as CD47, which inhibit phagocytosis (Wang et al, 2020). Engineered vesicles coated with glycosylated platelet membranes and interleukin-10 nanoparticles have been shown to promote M2 macrophage polarisation, reduce inflammation, and enhance endothelial repair (Li et al, 2023). Tail vein injection of platelet membrane-coated nanoparticles carrying bFGF and VEGFA plasmids effectively targeted burn injuries in rats and promoted tissue regeneration (Wang et al, 2023).
Novel platelet membrane-coated antibacterial nanoparticles (CSO@PM) exhibit strong bactericidal and anti-inflammatory effects while facilitating epithelialisation and collagen deposition, making them promising agents for treating drug-resistant infections in DFU (Peng et al, 2021). In recent research, Fe/Zn-based metal–organic frameworks encapsulated in platelet membranes formed nanozymes with enhanced peroxidase-like activity, effectively reducing pro-inflammatory cytokines, promoting angiogenesis, and accelerating wound healing in full-thickness infected mouse skin models (Shi et al, 2024). Nonetheless, their specific effects in diabetic wounds warrant further investigation.
Mechanisms and distinctions among platelet-derived therapies
Growth factors in PRP are the primary drivers of wound healing, while leukocytes, fibrin, antimicrobial peptides, and immunoglobulins also contribute significantly (Xu et al, 2020). PRP accelerates wound closure via haemostasis, modulation of inflammation, angiogenesis, and tissue remodelling. PRF and CGF form a three-dimensional fibrin mesh during centrifugation, allowing greater retention of platelets and leukocytes. PRF’s stable network structure supports sustained growth factor release and modulation of inflammation, particularly beneficial for chronic, non-healing wounds (Pan et al, 2016). CGF is produced using variable-speed centrifugation, enhancing fibrin structure stability and elasticity. This scaffold supports fibroblast and endothelial cell migration and proliferation while serving as a reservoir for bioactive molecules. CGF is enriched in leukocytes, TGF-β1, VEGF, and CD34+ cells, conferring superior anti-infective, angiogenic, and regenerative properties compared to PRF (Qin et al, 2016, Yang et al, 2025).
Outlook
Biological therapies are revolutionising DFU treatment, with platelet-derived products offering promising solutions. PRP, rich in growth factors, promotes tissue repair but requires additives and complex preparation, raising immunogenicity concerns. PRF, free of anticoagulants, enables slower growth factor release and is suitable for chronic wounds, though its efficacy is limited by lower growth factor concentrations. CGF combines high concentration with sustained release, significantly improving chronic wound healing and reducing recurrence risk, though standardisation and large-scale validation are still needed.
Emerging modalities like PRP-Exos and platelet membrane vesicles exhibit great potential. PRP-Exos, rich in growth factors and miRNAs, modulate key regenerative and anti-inflammatory pathways. Platelet membrane vesicles enable targeted delivery of therapeutic agents and enhance the wound microenvironment. Despite technical challenges in isolation and standardisation, their clinical prospects are encouraging.
Conclusion
Platelet-based biomaterials represent a promising frontier in DFU therapy. With continued innovation in preparation methods and clinical research, these biological agents may soon offer more effective, safer options for DFU management, improving outcomes and quality of life for affected patients.
