Tickle Me Fish

When I was in Prague recently, I passed a esthetician’s shop with an odd sight in the window.

2 for 1 Fish Pedicure

Apparently, they were having a sale, as “Akce Prijde ve dvou, platte jednou” roughly translates (according to Google Translate) as “Come in for one, get two”. Although I have heard of Fish Pedicures before, this is the first time I have actually seen someone’s feet in a fish tank.

Doctor fish, tickle fish, or more accurately  Garra rufa or Cyprinion macrostomum are both members of the carp (Cyprinidae  ) family. Both species are Aufwuchs feeders; that is, they eat the biocover that grows on rocks. When put in an environment separated from their natural diet they will feed on dead skin. Thus they are sometimes used as a treatment for psoriasis and other skin ailments.

The fish are native to Turkey and initially spread east, and from there into our western spas.

The garra rufa pedicure has a positive, proven history. The fish are part of the Cypriniformes family, hailing from Turkey, Syria, Iraq, and Iran. Turkey has recently implemented measures concerning the responsible export of the fish to ensure the avoidance of over harvesting. It is believed that inhabitants of Turkey have known of the healing and beauty properties of garra rufa fish since before scientists had given the fish a name. People from outlying areas began to visit popular springs containing the fish in the early 1800s. It wasn’t long before crude pools were constructed in order to benefit from the healing fish.
In the 50s and 60s several resorts were built, touting close proximity to the fish, as well as the healing spring water they came from. While locals had long since known of the beautifying effect that garra rufa fish have on the skin, sufferers of psoriasis have had the most dramatic results from the treatment. People from all over the world have visited Turkey specifically to treat their psoriasis with a garra rufa pedicure. Doctor fish have often accomplished what no creams or medications could accomplish, relief from the irritated, itchy red skin of psoriasis.
Outside of Turkey and its neighbouring countries, Asian countries were the first to export the fish for use in spas and salons. Eastern cultures and their affinity for natural solutions to health and beauty were a natural fit for garra rufa pedicure. Spas offering this service continue to grow in popularity throughout Asia and Europe.

The websites for companies offering the treatments usually list the supposed benefits of the pedicure. Although there are some variations, this list is fairly typical.

1. The overall cleanliness of the feet is improved.
2. Fish Pedicure / Manicure helps people with arthritis as this pedicure / manicure involves heat treatment
3. Feet are the most exposed part of the body. With Fish Pedicure / Manicure the feet are well hydrated and gain a fresh soft and supple look.
4. Corns, calluses, heel fissures and other foot conditions that can lead to major foot problem can be prevented through fish pedicure / manicure.
5. It helps in getting rid of skin smear and aging cortex. Unobstructed pore and promote blood circulation.
6. It stimulates acupuncture point and modulate nervous system to relax the body and release fatigue.
7. It’s a kind of biological therapy that cure various kind of skin diseases. This natural treatment proof effectiveness in common skin problems with no side effects. Several experiments have proven that no infectious diseases could be transmitted through this treatment process.
8. Treat your skin with nibbling that will remove excess dead surface cells, layers of skin that lose shine.
9. The nibbling process will bring back even and smooth softness and elasticity. It will also help to maintain a new rhythm of renewal and gives a healthy shine and a feeling of freshness.

As far as I can determine, there is no research to provide a basis for any of these claims, and certainly the stimulation of acupuncture points is a particularly ridiculous claim. If this actually occurred, why bother with needles in any acupuncture? But then studies have shown that toothpicks are as effective (ineffective) as needles, so why not fish?  One of the advantages of basing treatments on non-scientific principles is that you get to mix and match and mash them together however you want.

Like most variations of CAM, there is an immediate appeal to antiquity with claims of successful treatment of eczema and psoriasis and many other skin diseases and ailments for hundreds of years.

So far there have been few incidences of illness caused by fish pedicures, but they hardly have a 100% safety record. The US Center for Disease Control (CDC) recently released a letter from a group of UK researchers

Zoonotic Disease Pathogens in Fish Used for Pedicure

A survey during the spring of 2011 identified 279 fish spas in the United Kingdom, and the number has probably increased since then . The Fish Health Inspectorate of the Centre for Environment, Fisheries & Aquaculture Science estimates that each week 15,000–20,000 G. rufa fish are imported from Indonesia and other countries in Asia into the United Kingdom through London Heathrow Airport (the main border inspection post for the import of live fish). However, ichthyotherapy has now reportedly been banned in several US states and Canada provinces because of sanitary concerns. In the United Kingdom, a limited number of infections after fish pedicures have been reported. Unfortunately, little is known about the types of bacteria and other potential pathogens that might be carried by these fish and the potential risks that they might pose to customers or to ornamental and native fish.
On April 12, 2011, the Fish Heath Inspectorate investigated a report of a disease outbreak among 6,000 G. rufa fish from Indonesia that had been supplied to UK pedicure spas. Affected fish showed clinical signs of exophthalmia http://medical-dictionary.thefreedictionary.com/exophthalmia and of hemorrhage around the gills, mouth, and abdomen. More than 95% of the fish died before the remaining fish were euthanized. Histopathologic examinations identified systemic bacterial infections with small gram-positive cocci, mostly in the kidneys, spleen, and liver. Bacterial isolates cultured from affected fish were identified as Streptococcus agalactiae (group B Streptococcus) according to a combination of biochemical test results (API Strep; bioMérieux, Marcy l’Étoile, France), Lancefield grouping with serotype B (Oxoid Limited, Basingstoke, UK), and molecular (partial 16S rRNA gene sequencing) testing methods.

The researchers found that a number of pathogens in the fish were antibiotic resistant 

On histopathologic examination, the researchers identified systemic bacterial infections with small gram-positive cocci, which were identified as Streptococcus agalactiae (S. agalactiae), from the outbreak in April. In May and June of 2011, inspection of G. rufa fish, imported from Indonesia, revealed a taxonomically diverse range of bacteria, including human pathogens….all of which can cause invasive soft tissue infections. Isolates were resistant to a range of antimicrobial drugs.

Recently, the risks associated with exposure to G. rufa fish were reported to be low. To date, there are only a limited number of reports of patients who might have been infected by this exposure route. However, our study raises some concerns over the extent that these fish, or their transport water, might harbor potential zoonotic disease pathogens of clinical relevance. In particular, patients with underlying conditions (such as diabetes mellitus or immunosuppression) should be discouraged from undertaking such treatments, especially if they have obvious breaks in the skin or abrasions. This risk can probably be reduced by use of disease-free fish reared in controlled facilities under high standards of husbandry and welfare.

Fish pedicures are banned in some US States and Canadian Provinces. The CDC has information on why they are being restricted in the US.

Each state has the authority to ban fish pedicures. Currently, over 10 states have banned the use of fish pedicures
Most of the bans are based on at least one of the following reasons:

  • The fish pedicure tubs cannot be sufficiently cleaned between customers when the fish are present.
  • The fish themselves cannot be disinfected or sanitized between customers. Due to the cost of the fish, salon owners are likely to use the same fish multiple times with different customers, which increases the risk of spreading infection.
  • Chinese Chinchin, another species of fish that is often mislabeled as Garra rufa and used in fish pedicures, grows teeth and can draw blood, increasing the risk of infection.
  • According to the U.S. Fish and Wildlife Service, Garra rufa could pose a threat to native plant and animal life if released into the wild because the fish is not native to the United States.
  • Fish pedicures do not meet the legal definition of a pedicure.
  • Regulations specifying that fish at a salon must be contained in an aquarium.
  • The fish must be starved to eat skin, which might be considered animal cruelty.

The Health Protection Agency of the UK takes the following stance:

Fish tank water has been shown to contain a number of microorganisms.  Therefore,  in a fish spa setting there is the potential for transmission of a range of infections, either from fish to person (during the nibbling process), water to person (from the bacteria that can multiply in water), or person to person (via water, surrounding surfaces and fish).  However, the overall risk of infection is likely to be very low, if appropriate standards of hygiene are adhered to.
The fish spa working group concluded that those with weakened immune systems or underlying medical conditions, including diabetes and psoriasis, are likely to be at increased risk of infection and so fish pedicures are not recommended for such individuals.  The working group advised that operators of fish spas should not promote treatment to these groups.
Dr Hilary Kirkbride, consultant epidemiologist at the HPA, said: “Provided that good standards of hygiene are followed by salons, members of the public are unlikely to get an infection from a fish spa pedicure, however the risk will be higher for certain people.
“This is why we feel it’s important for salons to ensure the client has no underlying health conditions that could put them at risk, and that a thorough foot examination is performed, to make sure there are no cuts, grazes or existing skin conditions that could spread infection.
“Anyone considering a fish pedicure can help reduce the risk of infection – both to themselves and others – by taking simple precautions. Allowing any cuts or infections you may have on your feet or legs to heal before having the treatment, and waiting at least 24 hours after having a leg wax or shaving, will minimise your chances of catching anything. If you do experience any ill effects after the treatment, you should visit your GP.”
Dr Paul Cosford, Director of Health Protection Services at the HPA, added: “As with any beauty salon, it’s really important that strict standards of cleanliness are followed, to ensure that the risk of infection is kept to a minimum. If a member of the public is concerned about the level of cleanliness of a salon they visit, they should report this to their local Environmental Health department.”

So far, I have not been able to find a statement from Health Canada, but the Canadian Institute of Public Health Inspectors (CIPHI) Ontario  prepared a report on the availability of Fish Pedicures in Canada.

Montreal – One facility operating with public health unit knowledge and another location possible
Winnipeg – One facility which closed voluntarily
Ottawa – No facilities; representative states they would not approve
Toronto – No facilities; representative states they would not approve

British Columbia banned the pedicures in 2011

Prices in the UK start in the £12-15 range, while in the US, they cost approximately $35 for a 15 minute session, prices increasing with treatment time. Obviously in the Czech republic, you can get two for the price of one.
The limited research demonstrates a possible benefit for those suffering from psoriasis and eczema, however these are the very people who are recommended to avoid the spas. Other than the ick (ich?) factor, there appears to be very little risk to those who are healthy and have healthy skin, but then why bother?

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  • John Underhay

    John Underhay, also known as Peicurmudgeon, is just your average atheist, left leaning, SCUBA diving, snorkeling, biker. He lives on PEI and spends some of his time attempting to point out the flaws and or dangers in promoting ideas that run contrary to the laws of physics, chemistry, or biology. He has a BSc (Biology) and an MSc (Pharmacology) from the University of Prince Edward Island, and is currently retired. You can read more of his posts at http://peicurmudgeon.wordpress.com/