“Trendy fish pedicures could spread HIV and hepatitis C,” The Sun has today reported. Its front-page story said that officials have raised an “alert” over the treatment, popular in beauty spas, where tiny fish are used to nibble away areas of hard foot skin.

Although The Sun has been carping on about warnings and alerts, the newspaper seems to have overestimated the scale of the risk, which health experts have described as being “extremely low”. Rather than being an alert, the news is based on a report by the Health Protection Agency that has set out good practice for so-called ‘fish spas’ that offer the service.

While the report did acknowledge that the risk of infections could not be completely ruled out, it is important to view this in context and not be reeled in by fishy headlines.

What exactly is a fish pedicure?

A fish pedicure is a beauty treatment that uses dozens of tiny fish to nibble away dead and hardened skin from the feet. During a session a person immerses their feet in a tank of warm water and lets the minute, toothless Garra rufa fish nibble away for around 15 to 30 minutes. The fish are said only to eat dead skin, although there are some anecdotal reports that they can break the skin if they nibble too deep.

Fish pedicures have long been used as beauty treatments in Turkey and the Far East, but have only recently been introduced to this country. In the few years since the first UK ‘fish spa’ opened the treatment’s popularity has rocketed due to celebrity endorsements and high-profile press coverage. The HPA says that, as of spring 2011, it is aware of 279 in operation (although there are likely to be many more).

A small number of spas may also be using other species of fish to perform pedicures, such as Chin chin fish. However, the HPA says that these should not be used as they develop teeth when they get older, and may therefore present a greater risk to public health.

What did the report examine?

The report examined a number of issues relating to fish pedicures, including:

potential ways infections might occur

the risk of catching blood-borne viruses, including HIV and hepatitis

the risk of bacterial infections

the risk of catching parasites, such as fluke worms

the risk of transmitting conditions, such as athlete’s foot and verrucas

procedures that might reduce any health risks

The report is based on consultations with experts and professional bodies within the fields of public health, aquaculture, health and safety, and animal welfare.

What did the report find?

The report considered three main ways that a person might catch an infection:

from a fish or a fish tank

from tank water

from another person via surfaces, such as floors

Within these areas they considered the different types of infections that might occur.

Blood-borne viruses

Viruses such as HIV and hepatitis are carried in the blood and, in theory, could be transmitted through tank water if someone with a cut or abrasion were to use a tank containing traces of blood from an infected person with cuts.

However, there is only anecdotal evidence that Garra rufa fish can draw blood, and the HPA says that any blood-borne viruses they come into contact with are unlikely to stay on the surface of their mouths and lead to infection. Any blood entering the tank is likely to be diluted by the volume of water used.

While transmission through this method cannot be completely ruled out, the HPA says the risk of catching a blood-borne virus in this way is extremely low. Further to this, the HPA is recommending that the fish spas check clients for cuts and abrasions both before and after their session.

Parasites

Fish-borne parasites, such as tapeworms and flukes, can be caught by humans if they eat undercooked fish. However, the HPA says that there is no evidence that these can be caught from a fish pedicure as this would require ingestion of the fish or the water.

Bacterial infections

The report looked at a number of specific harmful bacteria, including those that cause salmonella and legionnaires’ disease. Generally, these were deemed to be of low risk as they would not be ingested or would need broken skin to cause infection.

However, certain bacteria were identified as posing a greater risk of infection. For example, Staphylococcus aureus might infect people’s skin if they have eczema or psoriasis. Also, a type of bacteria called Mycobacterium marinum, which is associated with fish tanks and non-chlorinated swimming pools, could cause boils if transferred into broken skin.

Fungal infections such as verrucas and athlete’s foot

Fungi are known to survive on inanimate surfaces for prolonged periods and could, therefore, be passed on by infected clients walking around barefoot. However, the HPA points out that this route of transmission is not unique to fish spas.

So are fish pedicures safe?

The Health Protection Agency says that “on the basis of the evidence identified and the consensus view of experts, the risk of infection as a result of a fish pedicure is likely to be very low”. The agency outlines some groups who are not recommended to have fish pedicures due to increased risk of infection, such as people with diabetes or compromised immune systems.

The HPA also specifically addresses the possibility of transmitting blood-borne viruses such as HIV and hepatitis. The agency says that, in theory, transmission could occur if infected blood from one person got into an open wound on another person using the same tank, although, once again, the risk is “extremely low”. In part, the risk would be minimised due to factors such as the diluting action of the water and the fact that infected blood would be unlikely to stay on the fishes’ mouths.

However, the agency does say that the risk of infections cannot be completely excluded and, in order to further reduce this risk, they have drawn up a list of recommendations for fish spas.

What recommendations does the HPA make?

The HPA has made extensive recommendations on how fish spas can further reduce the risk of infections. Below are some of the major ones.

Groups not recommended to have a fish pedicure

The agency also says fish pedicures are not recommended for people that may increase the risk of infection or pose an infection risk to other clients. This includes people who:

have had their legs waxed or shaved in the previous 24 hours (they may have tiny cuts that increase infection risk)

have any open cuts, wounds, abrasions or broken skin on the feet or lower legs

have an infection on the feet (including athlete’s foot or a verruca)

have psoriasis, eczema or dermatitis affecting the feet or lower legs

are diabetic (which leads to increased risk of infection)

have a blood-borne virus such as hepatitis B, hepatitis C or HIV

have an immune deficiency due to illness or medication

have bleeding disorders or take anticoagulant medication (for example, heparin or warfarin)

Safety procedures for fish spas

The HPA recommends that:

Clients should be provided with medical information on any potential risk, including specific guidance on conditions that raise infection risk.

Clients should have their feet examined both before and after treatment to make sure they are free from cuts and infections. Staff should log that these checks have been performed.

Feet should be thoroughly washed and rinsed before a pedicure to minimise the number of micro-organisms transferred into the tank.

If there is evidence that bleeding has occurred during a session the tank should be drained and cleaned thoroughly. The HPA has drawn up thorough guidelines on how to disinfect tanks in a fish-friendly way. After 48 hours in a holding tank the fish can be reused.

Clients should be told to seek advice from their GP if they experience any adverse effects.

Analysis by Bazian

Edited by NHS Website