Fish pedicure originated in Turkey, Syria, Iraq, and Iran and the healing and beauty properties of Garra Rufa fish (often referred to as Doctor Fish) have been known for hundreds of years. From the early 1800s tourists flocked to the Turkish Spa Pools in Kangal for fish nibbling sessions. Once the Turkish government realised the commercial worth of exporting Kangal garra rufa fish they banned the practice in 1996. By this time Doctor Fish Spas had become well established in Japan before rapidly spreading throughout Asia, mushrooming in countries like Singapore, Thailand and Malaysia. At the beginning of the millennium Doctor Fish Spas had opened in America. As a result of world wide limited supplies of the Doctor fish there are only a few companies in the world to offer first line or F1 original Turkish Kangal garra rufa fish, footbaths. Many of the garra rufa fish used in otherspa facilities are either cross-bred look-a-like fish or garra rufa fish from the second or further generation in line.
Garra rufa (sometimes called Doctor Fish) are a type of ray-finned fish in the family Cyprinidae. Garras are slim with a flat belly and a sucking mouth. Kangal garra rufa fish carry an enzyme, Dithranol, in the mouth. Dithranol is sometimes used in the treatment of psoriasis. Dipping feet into special baths containing up to 200 tiny toothless fish which then proceed to nibble away old skin cells leaving the new skin refreshed and invigorated became popular especially with tourists and subsequently spread to most other countries. Growing concerns over faux fish being used Dr Foot Spas were banned in the US for several years.This was later relinquished on the provision original garra rufa fish were used. As therapeutic fish nibbling has spread to Europe and the UK similar controls have been in place to resist the practice to F1 fish only. As economies dipped novelty fish pedicures were viewed with relish as revenue enhancer by struggling nail salons. However genuine concerns have continued because the fish could be source of cross contamination of blood borne viruses such as Hep C. The only way to prevent this would be to use the fish shoals once and once only which is cost prohibitive. Hence once again the practice of fish nibbling has been banned in several of the United States and Canadian provinces as cosmetology regulators believe the practice is unsanitary.
Human skin is made up of tiny cells, which are divided into two major layers. The lower Dermis contains all the blood vessels, nerves and fat lies below than the outer skin or epidermis which is an avascular (bloodless) layer.
The epidermis is very thin but made up of five distinct levels. As the lower cells pass upwards to the surface they become more compressed until they are cell-less flakes of keratin (protein). In order for the older keratin flakes to separate, squames (individual flakes) need a high water content which is the function of moisturising creams i.e. to add this water to the cells. In the normal course of events old squames leave the skin to be replaced by new ones so in effect like other animals we shed our skin every 28 days.
When the epidermis is damaged it may start to over produce Keritin (i.e. hyperkeratosis) and this presents either as callus or corns. Callus is a general distribution of hard skin (usually painless) whereas corns are more concentrated and can be painful. Biochemical factors in the blood determine the growth rate of the epidermal cells (which vary with individuals) and so damaged cells reproduce like normal cells but at a faster rate. This explains why callus and corns return when paired and the only way to deal with the concentrated mass of keratin (hyperkeratosis) is to physically scrape it away. Something we have known since the time of the Ancient Greeks when the original surgical scalpel was first invented to remove hard skin.
The key to any successful treatment is the safe removal of the keratin flakes and fish that nibble away skin cells, whilst novel, can be a valid way to control mild hyperkeratosis. Its usefulness is usually restricted to callus care and hence epi-dermabrasion by fish appears more in the range of beauty therapy than medical treatment but nibbling fish have been successfully used in the care of psoriatic skins (affects about 2-3% of the World Population).
There are two species of doctor fish; Garra Rufa and Cyprinion macrostomus , and they belong to the carp and minnow family. The fish have no teeth so cannot nibble (more importantly break into the dermis) but have a strong suck. Attracted to the many nutrients within human skin cells including those produced in healing wounds they swarm the skin plaque and proceed to lick it once it has been softened by the water. The constant ‘sucking’ by the younger fish has a gentle massaging effect on the recipient giving them a gently tingling sensation. Doctor fish can be used in the management of psoriasis and according to experts leave healthy keratin and only consume the affected and dead areas of the skin. Once old cells are removed (denuded) the clinician better access any underlying lesions which then may be treated in a more conventional way. F1 Kangal garra rufa fish used to feed on the skin of patients with psoriasis and eczema are breed in outdoor pools and only used under special conditions. Currently, there is no strong evidence to support the routine use of ichthyotherapy for psoriasis or other cutaneous diseases.
At first, the introduction of fish pedicure to mainstream beauty therapy caused no major alarm to authorities mainly due to the inability of the fish to damage healthy skin and no cases of cross infection were ever reported. Health authoritiesbecame more concerned however, at the potential to spread infections between people through open wounds. In the UK the Health Protection Agency (HPA) started to look more closely at fish pedicure and already some US states have banned them. HPA published a report Guidance on the management of the public health risks from fish pedicures (2011). Their report echoed the potential for cross infection and the need for consumers to bare this in mind when having a fish pedicure. Salons are recommended to use UV-lit tanks which are constantly filtered to keep them clear of disease. However not all salons are registered and policing standards presents a major challenge.
Scientific research demonstrates spa fish experience both behaviour and physiological changes as a result of skin nibbling. Levels of cortisol in overstocked tanks (similar to the numbers found in foot spas) was significantly higher than fish in optimally stocked environments. By comparison, other fish such trout, their cortisol levels drop when stocked in overcrowded conditions. Cortisol is a hormone created by the adrenal glands and scientists believe cortisol levels are a good indicator of chronic stress in fish.
Guidance on the management of the public health risks from fish pedicures (2011) Health Protection Agency
Shih T, Khan S, Shih S, et al. 2020 Fish Pedicure: Review of Its Current Dermatology Applications Cureus 12(6)