We have been tracking the emerging science of the wound microbiome on this blog for well over a decade — from Randy Wolcott’s early observations on “misanthropic microbial communities” (2009), to our own work with Spichler, Hurwitz, and Lipsky on microbiology from Louis Pasteur to “CSI” (2015), to the microbiome in wound healing — good, bad, ugly? (answer: yes), and more recently, randomized data on oral probiotics and DFU healing (2017), topical probiotics with metabolomic profiling from Venosi and colleagues (2020), the role of commensal bacteria via plasmacytoid dendritic cells from Nature Immunology (2020), gut microbiota and type 2 diabetes complications (2022), gut dysbiosis and DFU (2022), and harnessing probiotics for diabetic foot infections (2023).
The thread connecting all of this work has been a simple but radical idea: maybe the answer to hostile bacteria in a wound isn’t always killing them. Maybe sometimes it’s outcompeting them.
Now Karminska and colleagues from Poznan, Poland, have published a timely and comprehensive review in Cureus that pulls together the past decade of evidence on probiotic and postbiotic delivery systems for chronic wounds — specifically diabetic foot ulcers and burn wounds. It is well worth your time.
What the review covers
The authors conducted a structured PubMed search (2016-2026) and organized the evidence around three main strategies: (1) dressings containing viable probiotic microorganisms, (2) direct application of live strains in non-dressing formats, and (3) postbiotic-based therapies using cell-free supernatants, membrane vesicles, and biofilm derivatives.
The star of the show remains Lactobacillus plantarum, which appears across multiple delivery platforms — alginate microparticles, injectable hydrogels (ProGel), multilayer electrospun scaffolds, and even simple gauze. But the cast is growing: L. reuteri (including genetically modified strains producing the chemokine CXCL12), L. rhamnosus, L. paracasei, and probiotic yeasts like Saccharomyces cerevisiae and S. boulardii all make appearances, each with distinct mechanisms.
Why this matters for the diabetic foot
The mechanisms are multifold and fascinating. Probiotics secrete antimicrobial metabolites (organic acids, hydrogen peroxide, bacteriocins) that disrupt biofilms from the usual suspects — Staphylococcus aureus and Pseudomonas aeruginosa. They modulate the immune response, pushing macrophages from M1 (pro-inflammatory) to M2 (pro-repair) phenotypes — something we have discussed at length here. They acidify the wound environment. And some formulations — like the LR&AB@CAH alginate gel — actually consume excess glucose in the diabetic wound bed, reduce local hyperglycemia, and trigger cascading antioxidant responses.
The delivery science is getting increasingly clever: biohybrid microneedles loaded with live S. cerevisiae for sustained intradermal delivery, photopolymerized hydrogels, metal-phenolic self-assembly shields that protect probiotics from concurrent antibiotic therapy, and “living bacterial hydrogels” that achieve full wound closure by day 10 in infected mouse models.
The reality check
The authors are appropriately measured: most evidence still comes from in vitro and animal models. Robust RCT data in humans remains scarce. No head-to-head comparisons of delivery platforms exist. Strain selection, formulation heterogeneity, and outcome measures vary widely across studies. We are, in short, still in the early chapters of this story.
But the trajectory is clear, and the logic is compelling. In a world where antimicrobial resistance is rising, chronic wounds cost an estimated $25 billion annually in the US alone, and biofilm-mediated infections remain one of our biggest clinical headaches, the idea of deploying “bugs as drugs” — live microbial therapeutics that can outcompete pathogens, modulate immunity, and actively participate in tissue repair — is an idea whose time is approaching.
Stay tuned.
Citation: Karminska M, Czernikiewicz K, Glowacka-Kaminska W, et al. (March 12, 2026) Probiotic and Postbiotic Delivery Systems for the Management of Chronic Wounds: A Review of Emerging Strategies. Cureus 18(3): e105081. DOI: 10.7759/cureus.105081
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