This month (September, 2018), JAMA-Dermatology published a report by Dr. Shari Lipner describing a case of onychomadesis with nail loss in a woman who was treated at a fish spa (JAMA Dermatol. 2018;154(9):1091-1092).  Although we do not really know whether the fish spa was the cause of this problem, fish spas have been associated with several problems in the past, like bleeding and infections, making this new report of nail loss quite likely to be the result of the fish spa.  Dr. Lipner should be praised for identifying the possible connection between this illness and the fish spa.


But we take issue with the accusation that the Doctor Fish, Garra rufa, was to blame. Garra rufa has been reported to provide medicinal and health benefits, and is used by many as part of fish therapy (ichthyotherapy). But fish spas are not fish therapy, and most fish spas in Asia and North America use a less expensive and more plentiful fish, such as Tilapia. (Grassberger & Sherman. Ichthyotherapy. In: M. Grassberger et al, eds. Biotherapy – History, Principles and Practice. Springer Science+Business Media; 2013:147-76). Many fish spa operators do not even know they are using Tilapia because young Tilapia look very similar to Garra rufa. But tilapia, such as the Chin Chin fish or Oreochromis species are very different:  they have teeth, they are more aggressive than Garra rufa, they can cause pain, occasionally draw blood, and have not been associated with health benefits.  Garra rufa has no teeth and is the only fish to repeatedly demonstrate health benefits.


The author of this recent medical report provided no evidence that the fish at the spa were ever identified; she simply assumed that Garra rufa was to blame because it is the species used in fish therapy.  Given the probability that a different fish species was swimming in the accused fish spa, and given the lack of any reported identification of the fish at the spa, we believe that if a fish was responsible for this illness, it was most likely not Garra rufa.


The Journal editor was notified of this fact, but chose to print the paper this month without modification and without acknowledging the submitted review concerning the fact that the evidence did not support the Garra rufa claim.  Not only does this negligence detract from the normally high standards of the AMA publications, but it seriously jeopardizes support for legitimate ichthiotherapy research with Garra rufa.  Had the patient reported using a “cream” at the fish spa, no responsible author or editor would have blamed a specific brand of medication for the clinical outcome without verifying the identity of that “cream.” Yet the JAMA reviewers and editors did not afford the Garra rufa the same respect; they did not request proof of the identity of the fish at the “fish spa” before printing their condemnation of Garra rufa.


We invite you to submit a letter to the Editor of JAMA-Dermatology, reminding her of these facts.  A draft letter and a one-button submission form can be found on this page.


We also invite you to consider writing a comment on one or two webpages that have repeated this possibly erroneous claim. A link to those websites can be found on this page. By now, scores of news and media outlets have spread this misinformation, and all that we can do is call attention to the fact that . . . the story may not be all the facts.


Again, sample letters appear on both linked sites.  Modify them to meet your personal style and comfort.  Let us know if you have any additional thoughts or concerns.


Thank you for your assistance in correcting the biomedical record.  Thank you for helping to save the reputation of Garra rufa, and the future of ichthyotherapy research.