New Diagnostic Strategy for Onychomycosis: First-Line Utilization of DermaGenius® PCR and Calcofluor Microscopy Combined with Selective Culturing

Abstract

Onychomycosis (OM) is a widespread infection requiring prolonged treatment with potential side effects. Diagnostic certainty is therefore essential before initiating antifungal therapy. Molecular biology has already shown benefits in reducing the time to diagnosis, providing technical ease, and increasing sensitivity for the respective species that molecular tests can detect. Nevertheless, causative agents are numerous, and culture remains essential, particularly for detecting non-dermatophytes mold infections. This study compared the performance of three different diagnostic strategies: conventional culture technique, the multiplex DermaGenius® 2.0 PCR (DG), and a mixed PCR/culture algorithm guided by the result of direct examination with calcofluor (DEC). The mixed algorithm (MA) prioritizes DG PCR and DEC as the primary diagnostic tools, supplemented by selective sample inoculation when mycelial elements are visualized in DEC and when DG PCR fails to detect any fungus or identifies a fungus with morphology differing from that observed in DEC (filamentous fungi versus yeasts). With only 13% of samples requiring inoculation, MA emerged as the most effective strategy, demonstrating significantly higher sensitivity (98.18%; p < 0.001) compared to single-method approaches (78.18% for DG PCR alone and 74.55% for culture alone) while maintaining a specificity comparable to DG PCR (100%). This new approach saves time in result delivery, requires fewer human resources, and increases diagnostic accuracy to better meet the needs of clinicians.