Fish pedicure can damage toenail growth plate


By Will Boggs MD

NEW YORK (Reuters Health) - Fish pedicure can result in damage to the toenail growth plate, a condition known as onychomadesis, according to a case report.

"There are a number of real and theoretical risks associated with fish pedicures and relatively little benefit," Dr. Shari R. Lipner from Weill Cornell Medicine, New York told Reuters Health. "Known risks are onychomadesis, Staphylococcus aureus infections, and Mycobacterium marinum infections. Theoretical risks include other infections, such as HIV and hepatitis. Therefore, I recommend that we advise our patients to avoid fish pedicures."

Fish pedicure involves immersion of the feet in a tub of water containing small fish called Garra rufa, which can eat human skin. Claims that the treatment leaves feet smoother, eliminates fungus and bacteria, and treats psoriasis and eczema are unfounded.

Tubs and fish cannot be adequately sanitized between people, and the same fish are typically reused for successive individuals, raising concerns of transmitting infections between people undergoing fish pedicure. At least 10 states in the US have banned its use.

In JAMA Dermatology, online July 3, Dr. Lipner describes the development of onychomadesis in a woman in her 20s beginning several months after a fish pedicure. She had no other history of trauma, no family history of nail disorders, no medical problems, no history of major illness or high fever, and no vaccinations or use of medications in the past year.

The proximal nail plate was discontinuous with the distal nail plate on both first, second, and third toenails, with disappearing nail bed on both first toenails, findings consistent with the diagnosis of onychomadesis, according to the report.

Onychomadesis has been associated with major medical illnesses, infections, systemic disease, autoimmune disease, medications, hereditary conditions, and idiopathic causes, but this is the first reported case of onychomadesis associated with fish pedicure.

"I think it is under-recognized and underreported by both physicians and patients, but probably fairly common," Dr. Lipner said by email. "Remember that onychomadesis typically presents several months after the inciting event, due to naturally slow nail growth rate, so patients usually do not make the connection with prior insults."

"Physicians should be aware of the differential diagnosis of onychomadesis, and ask their patients about prior fish pedicures while taking a thorough history," she said. "Physicians should also be aware of the infectious risks associated with fish pedicures."

"(Since) the theoretical risks include other infections, such as HIV and hepatitis, a thorough workup for these infections should be performed if the patient reports history of a fish pedicure," Dr. Lipner said.

Dr. Gianluca Nazzaro from University of Milan, Italy, who earlier reported S. aureus infection of the feet following fish pedicure, told Reuters Health by email, "Patients should be advised about risks of fish pedicure, especially the ones suffering from diabetes or immunosuppression or dermatitis, because of the increased risk of skin infection."

"Physicians, especially general practitioners, should inform their patients about this risky procedure," he said.


JAMA Dermatol 2018.

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