Fungal detection, diagnostic approaches, and antifungal susceptibility in diabetic foot ulcers: a systematic review of recent evidence

Background Fungal infections are an emerging but underrecognized concern in diabetic foot ulcers (DFU); and may contribute to delaying healing and complicate clinical outcomes. This study reviewed available evidence to identify the neglected contribution of fungi to DFUs and to explore their antifungal susceptibility patterns. Methods A systematic search in PubMed, Web of Science, and Google Scholar databases for articles published from 2021 to 2025. Eligible articles were screened, extracted, and reported according to PRISMA guidance, and methodological quality was assessed using JBI tools. Results Of the 1,030 publications identified, 26 studies comprising 3,851 patients met the inclusion criteria, all reporting fungal involvement in DFUs. Candida spp. were the most commonly isolated organisms, with fluconazole resistance reaching up to 23%. Filamentous fungi accounted for 21.2% of reported cases, predominantly Aspergillus niger and Aspergillus fumigatus ; Rhodotorula mucilaginosa and Cutaneotrichosporon debeurmannianum were also identified. Conclusions These findings suggest a potentially important role of fungi in DFUs; however, evidence on antifungal susceptibility remains limited. Therefore, greater attention to fungal involvement is warranted to reduce infection burden, minimize complications, and improve health outcomes and quality of life in patients with diabetes. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261404556 , identifier CRD420261404556.