A lovely piece by our friend and colleague Alisha Oropallo and her team at Northwell, just out in the International Wound Journal. The question they ask is one we should be asking more loudly: before you reach for a CAMP (cellular/acellular/matrix-like product, i.e., a “skin substitute”) on a chronic DFU or VLU, what is the actual bioburden of the wound bed you are about to cover?
In this single-blinded prospective pilot of 10 patients, the team imaged each ulcer with bacterial fluorescence (MolecuLight) immediately before placing the skin substitute, then tracked wound area reduction at 4 ± 1 weeks. Small n, loud signal:
— 4 of 5 fluorescence-negative wounds hit the 40% wound area reduction mark.
— 0 of 5 fluorescence-positive wounds did. (p < 0.05)
— Fluorescence-negative wounds shrank by 68.0%.
— Fluorescence-positive wounds grew by 33.7%. Yes, grew.
In other words: when you apply a several-hundred (sometimes several-thousand)-dollar graft to a wound bed carrying a moderate-to-heavy bacterial load, you are largely feeding the bacteria, not the patient. The graft does not become tissue. It becomes lunch.
This is the theragnostic argument many of us have been making for years on this site (see prior posts on fluorescence-guided debridement, hyperspectral imaging, and the broader theragnostics archive linked below). The point of a real-time, point-of-care bioburden signal is not just to confirm what we already suspect — it is to gate the next decision.
So here is the actionable version, which is what Alisha’s paper actually lets us put up on a clinic wall:
When to START a CAMP / skin substitute:
— Wound has been adequately debrided.
— Vascular status is adequate, offloading is in place, glycemic control is in motion.
— Standard care has failed to produce ≥ 40–50% area reduction at 4 weeks (the long-standing benchmark).
— Bacterial fluorescence at the point of application is NEGATIVE. Green light. Apply.
When to WAIT (or stop, or switch) before reaching for a CAMP:
— Fluorescence-POSITIVE wound bed at the moment of planned application. Do not place the graft. You are more likely to make the wound bigger than smaller.
— Instead: re-debride (ideally fluorescence-guided), reassess infection management, optimize wound bed prep, and re-image before deploying the graft.
— Re-evaluate vascular inflow and offloading if the FL signal will not clear.
— Only when the wound is FL-negative do you “spend” the graft.
That is the spirit of theragnostics in our world: a diagnostic that directly changes whether and when a therapy is deployed. Bioburden imaging is not a thermometer telling you the room is warm; it is closer to a smoke detector telling you whether it is safe to light the candle.
Two caveats, in the interest of intellectual honesty:
— n = 10. This is a hypothesis-confirming pilot, not a definitive RCT. The effect size and the convergence with prior MolecuLight literature on wound bed prep are what make it worth acting on now.
— Fluorescence imaging detects bacteria at moderate-to-heavy loads (roughly ≥ 10⁴ CFU/g). A negative scan is not a sterile field; it is a field below the threshold most likely to sabotage a graft.
Bottom line: in a world where CAMPs are widely used, often expensive, and increasingly scrutinized for value, this is exactly the kind of decision-support evidence the field needs. Image first. Apply second. Re-image if the wound stalls.
Lovely work, Alisha and team.
Read the paper: Oropallo A, Rao AS, Kaplan S, Baksh F, Isgro J, Iddriss A, Del Pin C. Absence of Bacterial Fluorescence Is Associated With Early Response to Skin Substitutes in Diabetic and Venous Ulcers: A Single-Blinded Prospective Study. Int Wound J. 2026 May;23(5):e70951. https://doi.org/10.1111/iwj.70951 | PubMed: https://pubmed.ncbi.nlm.nih.gov/42171400/
Related from DFOnline:
— Current and Future Directions in Fluorescence Imaging Guided Debridement (Orkin R, Sharma A, Armstrong DG, John JV, 2024): https://diabeticfootonline.com/2024/07/07/current-and-future-directions-in-fluorescence-imaging-guided-debridement-actagainstamputation-diagnostics-theragnostics-researchatusc-usc_vascular-keckschool_usc/
— Point-of-care fluorescence imaging reveals extent of bacterial load in DFUs (2023): https://diabeticfootonline.com/2023/01/29/point-of-care-fluorescence-imaging-reveals-extent-of-bacterial-load-in-diabetic-foot-ulcers-actagainstamputation-diagnostics-theragnostics-diabeticfoot/
— Hyperspectral Imaging to Predict DFU Healing (2023): https://diabeticfootonline.com/2023/01/16/use-of-hyperspectral-imaging-to-predict-healing-of-diabetic-foot-ulceration-diagnostics-theragnostics-actagainstamputation-alpslimb/
— Skin Substitutes for DFUs and VLUs: A Health Technology Assessment @OntarioHealthOH (2021): https://diabeticfootonline.com/2021/07/04/skin-substitutes-for-adults-with-diabetic-foot-ulcers-and-venous-leg-ulcers-a-health-technology-assessment-ontariohealthoh/
— Full theragnostics archive: https://diabeticfootonline.com/tag/theragnostics/
#ActAgainstAmputation #Diagnostics #Theragnostics #MolecuLight #Fluorescence #BacterialBurden #CAMPs #SkinSubstitutes #DiabeticFoot #DFU #VLU #WoundHealing #WoundCare #LimbPreservation
Leave a Reply