Infection (2014) 42:925926
DOI 10.1007/s15010-014-0622-4
CASE REPORT
Staphylococcus aureus infection of the feet following fish pedicure
S. Veraldi G. Nazzaro E. Cuka
Received: 2 February 2014 / Accepted: 11 April 2014 / Published online: 26 April 2014
Springer-Verlag Berlin Heidelberg 2014
Abstract We report a case of Staphylococcus aureus
infection of the feet that appeared after a fish pedicure
(immersion of the feet in a tank with the fish Garra rufa,
that nibbles off dead skin). Clinical picture was charac-
terized by maceration, purulent discharge, scales, crusts,
itching and burning sensation. Bacteriological examina-
tions were positive for Staphylococcus aureus. Mycologi-
cal examinations were negative. The patient was
successfully treated with ciprofloxacin. Only one case of
skin foot infection after fish pedicure was reported so far.
Fish pedicure can be a potentially dangerous procedure in
immunocompromised or diabetic patients.
Keywords Skin infection
Staphylococcus aureus
Fish
pedicure
Garra rufa
Introduction
Fish pedicure consists of the immersion of the feet in a
tank with fish, in particular Garra rufa, that nibbles off dead
skin. This procedure is becoming rather popular in some
European countries. Even though only one case of skin foot
infection caused by Staphylococcus aureus after fish pedi-
cure was reported so far, this practice can be potentially
dangerous in immunocompromised or diabetic patients. We
S. Veraldi
G. Nazzaro (&)
E. Cuka
Department of Pathophysiology and Transplantation, University
of Milan, IRCCS Foundation, Ca Granda Ospedale Maggiore
Policlinico, Via Pace 9, 20122 Milan, Italy
e-mail: gianluca.nazzaro@gmail.com
S. Veraldi
e-mail: stefano.veraldi@unimi.it
report a case of Staphylococcus aureus infection of the feet in
a woman who acquired the infection in Greece.
Case report
A 39-year-old woman was admitted because of a dermatitis
located on both her feet. The patient stated that the der-
matitis appeared 3 days earlier, during summer holidays in
the island of Karpathos (Greece), where she made the fish
pedicure (immersion of the feet in a tank with fish that
nibble off dead skin). The patient complained of itching
and burning sensation. Dermatological examination
revealed a dermatitis involving almost all interdigital
spaces of both feet. It was characterized by maceration,
purulent discharge, scales and crusts (Fig. 1). Bacterio-
logical examinations (three samples) were positive for
Staphylococcus aureus. Three mycological examinations
were negative. The patient was treated with 0.05 % sodium
hypochlorite footbaths and oral ciprofloxacin (500 mg/day
for 10 days). Complete remission was observed 5 days
after the beginning of the therapy. Follow up (9 months)
was negative.
Discussion
Kangal hot spring is located in Turkey, approximately
500 km east of Ankara and 14 km north of the town of
Kangal. There are several pools with a total capacity of
130 l/s in the spa. The temperature of the water ranges
from 35 to 37 C; the pH is 7.8. Calcium and magnesium
are the two most important cationic elements [1]. Two
different species of fish, both belonging to the Cyprinidae
family, live in these pools: Cyprinion macrostomus
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Fig. 1 Maceration and purulent discharge at the fourth interdigital
fold of the left feet
macrostomus Heckel 1843 and the doctor fish Garra
rufa obtusa Heckel 1843. Because of insufficient amount of
phytoplankton and zooplankton in the pools, human skin is
an attractive food source for these omnivorous fish [1].
This was the reason for which, since the 1980s, these fish
were employed for the treatment of psoriasis [24]. Some
controlled clinical trials supported the efficacy and safety
of this ichthyotherapy, alone or in combination with
ultraviolet rays [1, 5]. However, some authors also
observed that these fish can cause skin lesions that result in
worsening of psoriasis (Koebners phenomenon) [3]. Garra
rufa was subsequently used for pedicure (fish pedicure).
In some countries, fish pedicure currently is a rather pop-
ular cosmetic procedure. Since 1989, it was hypothesized
that the water of Kangal hot spring and/or the fish could
transmit hepatitis or HIV [2]. This risk would be supported
by the fact that, at least in Italian shops where the fish
pedicure is carried out, the water is not disinfected, because
Garra rufa is very susceptible to water disinfectants [6].
However, no cases of hepatitis or HIV transmission have
been reported in the literature. Despite this, very little
information is available regarding the health of these fish
and the range of potential microorganisms they can carry
[7]. Group B Streptococcus agalactiae was isolated from
kidneys of the fish and found to be resistant to several
antibiotics. In addition, a virus belonging to a serogroup C
aquabirnavirus was isolated. However, no clinical signs of
bacterial or viral infections were observed in any fish
123
S. Veraldi et al.
examined [7]. No clinical signs of disease were found,
which means that these fish look healthy, but they are not.
Furthermore, Aeromonas sobria was identified as causative
agent of hemorrhages and massive fish mortality [8]. These
observations indicate that Aeromonas sobria can act as an
important pathogen of Garra rufa and that it can be a risk
factor for immunodeficient patients during ichthyotherapy
or fish pedicure. However, only one patient with skin foot
infection caused by methicillin-resistant Staphylococcus
aureus after fish pedicure was reported so far [6]. In our
patient, Staphylococcus aureus infection might have been
contracted according to different modalities. However, the
close (2 days) temporal relationship between the fish ped-
icure and the appearance of clinical manifestations in a
previously healthy woman would support the etiopatho-
genetic role of fish pedicure. Furthermore, the patient was
visited by one of us (SV) 5 days before her trip to Greece
because she was affected by multiple dysplastic nevi:
dermatological examination, including interdigital folds of
the feet, was negative for mycotic and bacterial infections.
It was possible to establish that the fish used for pedicure
were Garra rufa. However, it was impossible to study
water samples of the tanks. In conclusion, fish pedicure is
very rarely responsible for bacterial infections of the skin,
although Garra rufa is susceptible to several microorgan-
isms. However, fish pedicure can be a potentially danger-
ous procedure in immunocompromised patients or affected
by diabetes.
Conflict of interest On behalf of all authors, the corresponding
author states that there is no conflict of interest.
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