Fungal Nails? DNA Facts Challenge Dystrophic Etiology.

BACKGROUND: Historically recalcitrant to treatment, infection of the nail unit is a pervasive clinical condition affecting approximately 10% to 20% of the US population; patients present with both cosmetic symptomatology and pain, with subsequent dystrophic morphology. To date, the presumptive infectious etiologies include classically reported fungal dermatophytes, nondermatophyte molds, and yeasts. Until now, the prevalence and potential contribution of bacteria to the clinical course of dystrophic nails had been relatively overlooked, if not dismissed. Previously, diagnosis had largely been made by means of clinical presentation, although microscopic examinations (potassium hydroxide) of nail scrapings to identify fungal agents and, more recently, panel-specific polymerase chain reaction assays have been used to elucidate causative infectious agents. Each of these tools suffers from test-specific limitations. METHODS: Molecular-age medicine now includes DNA-based tools to universally assess any microbe or pathogen with a known DNA sequence. This affords clinicians with rapid DNA sequencing technologies at their disposal. These sequencing-based diagnostic tools confer the accuracy of DNA-level certainty, and concurrently obviate cultivation or microbial phenotypical biases. RESULTS: Using DNA sequencing-based diagnostics, the results in this article document the first identification and quantification of significant bacterial, rather than mycotic, pathogens to the clinical manifestation of dystrophic nails. CONCLUSIONS: In direct opposition to the prevailing and presumptive mycotic-based causes, the results in this article invoke questions about the very basis for our current standards of care, including effective treatment regimens.

A review of iodine-based compounds, with a focus on biofilms: results of an expert panel.

Biofilms play a central role in the chronicity of non-healing lesions such as venous leg ulcers and diabetic foot ulcers. Therefore, biofilm management and treatment is now considered an essential part of wound care. Many antimicrobial treatments, whether topical or systemic, have been shown to have limited efficacy in the treatment of biofilm phenotypes. The antimicrobial properties of iodine compounds rely on multiple and diverse interactions to exert their effects on microorganisms. An expert panel, held in Las Vegas during the autumn Symposium on Advanced Wound Care meeting in 2018, discussed these properties, with the focus on iodine and iodophors and their effects on biofilm prevention and treatment.

Treatment Options to Manage Wound Biofilm.

BACKGROUND: Bioburden is an accepted barrier to chronic wound healing. Defining the significance, phenotype, clinical classification, and treatment guidelines has been historically lacking of evidence and based on paradigms that do not represent the scientific or clinical reality. THE PROBLEM: Chronic wound bioburden is typically abundant, polymicrobial, and extremely diverse. These microbes naturally adopt biofilm phenotypes, which are quite often viable but not culturable, thereby going undetected. The failures of culture-based detection have led to abandonment of routine bioburden evaluation and aggressive treatment or, worse, to assume bioburden is not a significant barrier. Predictably, treatment regimens to address biofilm phenotypes lagged behind our diagnostic tools and understanding. BASIC/CLINICAL SCIENCE ADVANCES: Microbial DNA-based diagnostic tools and treatment regimens have emerged, which provide and leverage objective information, resulting in a dramatic impact on outcomes. RELEVANCE TO CLINICAL CARE: Modern medicine demands decisions based on objective evidence. The diagnostic and treatment protocols reviewed herein empower clinicians to practice modern medicine with regard to bioburden, with DNA level certainty. CONCLUSION: Bioburden is a significant barrier to healing for all chronic wounds. Molecular diagnostics provide the first objective means of assessing wound bioburden. The accuracy and comprehensive data from such diagnostic methodologies provide clinicians with the ability to employ patient-specific treatment options, targeted to each patient's microbial wound census. Based on current outcomes data, the most effective therapeutic options are topical (TPL) antibiofilm agents (ABF) combined with TPL antibiotics (ABX). In specific patients, systemic ABX and selective biocides are also appropriate, but not exclusive of ABF combined with TPL ABX.