Fish pedicures: ANSES recommends significant and rigorous changes in practice

It has long been a common practice in Turkey, Asia and the Middle East to immerse all or part of the body in water containing fish (generally the species Garra rufa ⁽¹⁾ ) for the removal of dead skin particles. In several countries, including France, an increasing number of establishments now offer this type of treatment – especially the type known as a fish pedicure – claiming aesthetic or wellness benefits, and also in some cases therapeutic effects.

Against this background, ANSES was requested by the Ministry of Health to carry out a risk assessment on the possible transmission of diseases via fish or the water. The work carried out by the Agency focused on the risks related to immersion of the feet, exclusively for aesthetic and/or “wellness” purposes.

The Agency’s expert appraisal

To carry out this work, the Agency set up a dedicated group of experts with complementary skills including scientists specialising in risks related to water, microbiology, fish health and dermatology and involving two of its Expert Committees.

The following points arose during the Agency’s study: 

• in France, fish pedicures are not governed by any specific health regulations;
• since 2010, fish pedicures have become increasingly available in Europe, especially in France in beauty or “wellness” salons where they are offered alongside other treatments. It is not possible to determine the extent of this practice in France with any precision but it would seem that several hundred establishments offer fish pedicures, of which only a few dozen satisfy the applicable legal requirements ^(2);
• cases of bacterial infection linked to fish-keeping and fish pedicures have been described;
• there is little information available about the quality of the water in establishments practicing fish pedicures and there are no data specifically about the presence and prevalence of pathogenic micro-organisms in Garra rufa sold in France;
• it is not possible to keep the water adequately disinfected in tanks used for fish pedicures, as this would kill the fish present;
• there is a higher risk of infection with certain groups of users (diabetics, the immune-compromised, users with dermal lesions on the feet);
• people with excessively thick skin (hyperkeratosis), sometimes caused by mycoses, may be especially drawn to fish pedicures, therefore increasing both the risk for these individuals who suffer from higher sensitivity to infection, and the risk of water contamination in general due to their mycoses.  

The Agency’s conclusions

Considering these different elements and although no cases of infection related to fish pedicure use have been documented to date, the Agency considers that there is a potential risk of transmission of pathogens of human or animal origin via the water or the fish, during fish pedicures. The risk is probably low, except for especially susceptible user groups, but in the absence of data it is not currently possible to quantify this risk. Consequently, the Agency recommends that data be collected to enable the health risk to be characterised in detail and to identify cases of infection related to visits to establishments offering this type of pedicure.

Furthermore, ANSES deems it necessary to regulate fish pedicure practices with suitable provisions, in order to ensure: 

• that fish pedicure tanks contain water that guarantees protection of users against the risk of infection; 
• admission procedures and user hygiene, with the hygiene of the establishment being under the responsibility of qualified personnel; 
• both inspection and self-monitoring of the facilities and their operation, in terms of water quality in the tanks and the general hygiene of the establishment; 
• mandatory traceability of batches and health inspections of the fish;
• objective public information about the potential risks of this practice; 
• information for personnel, including temporary staff, trainees and the staff of outside companies working within the establishment, on the risks of infection, especially by multiple antibiotic-resistant strains of bacteria, and the need to comply with workplace hygiene rules;
• training for the personnel of these establishments to ensure their safety and that of users.

Lastly, the Agency emphasises the need to apply the regulations governing wild animals held in captivity which also govern the conditions for opening establishments offering fish pedicures.

⁽¹⁾ Or, less commonly, the Nile tilapia (Oreochromis niloticus), which is sometimes used in Asian countries and which presents a greater risk as, unlike Garra rufa, it has teeth capable of damaging users’ skin. The Agency’s study concerned only Garra rufa.

⁽²⁾ In compliance with regulatory provisions on the protection of animals in captivity.