PRISM: incorporating advanced imaging technologies into a comprehensive strategy for hard-to-heal wound assessment and management

Head-to-heal wounds—particularly diabetic lower-extremity wounds—remain among the most challenging and resource-intensive problems in contemporary healthcare, with five-year recurrence rates of 40–65% and a trajectory toward amputation that is frequently driven by three interacting and often under-recognised failures: inadequate perfusion; unrecognised bacterial burden; and unaddressed biomechanical deformity. Near-infrared spectroscopy (NIRS) and bacterial autofluorescence (BAF)—two point-of-care optical imaging technologies—now permit objective, real-time characterisation of the two dominant modifiable barriers to healing: tissue oxygenation and bacterial load. PRISM (perfusion imaging, regional bacterial status, infection staging, structural correction, and maintenance and monitoring) is a structured, imaging-first algorithm that organises these technologies into a single, sequential pathway for hard-to-heal wound assessment and management. This article reviews the operating principles and clinical evidence for NIRS and BAF, expands each of the five PRISM components in a stepwise clinical description, and presents an integrated decision matrix-tree that translates combined imaging findings into actionable, point-of-care interventions. By anchoring every clinical decision in real-time imaging data rather than clinical impression alone, PRISM offers a reproducible framework for earlier identification of healing barriers, more targeted therapy, antimicrobial stewardship, objective longitudinal monitoring and limb preservation.