Maggot Debridement Therapy
The following information was written by Ronald A.
(Note: If you are trying to obtain medical grade maggots in the
USA or Canada, please contact
Maggot Debridement Therapy (MDT) is the medical use
of live maggots (fly larvae) for treating non-healing wounds.
In maggot debridement therapy (also known as maggot therapy, larva
therapy, larval therapy, biodebridement or biosurgery), disinfected
fly larvae are applied to the wound for 2 or 3 days within special
dressings to keep them from migrating. The literature identifies
three primary actions of medical grade maggots on wounds:
They clean the wounds by dissolving dead and
infected tissue ("debridement");
They disinfect the wound (kill bacteria);
They speed the rate of healing.
The following topics about maggot therapy are
History of Maggot Therapy
Maggots have been known for centuries to help heal
wounds. Military surgeons noted that soldiers whose wounds became
infested with maggots had better outcomes than those not infested.
William Baer, while at Johns Hopkins University in Baltimore,
Maryland, may have been the first in the Northern Hemisphere to have
intentionally applied larvae to wounds in order to induce wound
healing. During the late 1920's, he identified specific species,
raised them in the laboratory, and used their larvae to treat
several children with osteomyelitis and soft tissue infections. He
presented his findings at a surgical conference in 1929. Two years
later, after treating 98 children, his findings were published
MDT was successfully and routinely performed by thousands of
physicians throughout the 1930’s, but soon it was supplanted by the
new antibiotics and surgical techniques that came out of World War
II. Maggot therapy was occasionally used during the 1970's and
1980's, but only when antibiotics, surgery, and modern wound care
failed to control the advancing wound.
The first modern clinical studies of maggot therapy were initiated
in 1989, at the Veterans Affairs Medical Center in Long Beach, CA,
and at the University of California, Irvine, to answer the following
"Is maggot therapy still useful today?"
"Should maggot therapy be used as an adjunct to
other treatments, not merely as a last resort?"
"How does maggot therapy compare to other treatments
at our disposal?"
The results of those controlled comparative clinical trials and the
many studies and reports that followed, indicate that MDT is still
useful today as a safe and effective treatment tool for some types
of wounds. Those studies also demonstrated that there is no reason
to withhold MDT until all other modalities have been exhausted, nor
use it only as a “last resort.” Indeed, while published accounts of
“pre-amputation MDT” show a limb salvage rate of over 40%, the
success of MDT when used earlier in the course of treatment (say, as
a 2nd or 3rd or 4th line treatment) is even more dramatic.
Current status of
In 1995, a handful of doctors in 4 countries were using MDT. Today,
any physician in the U.S. can prescribe maggot therapy. Over 4,000
therapists are using maggot therapy in 20 countries. Approximately
50,000 treatments were applied to wounds in the year 2006.
In January 2004, the U.S. Food and Drug Administration (FDA) began
regulating medicinal maggots, and allowed the production and
marketing of one particular strain of Phaenicia sericata larvae
marketed under the brand name Medical Maggots (TM). In February,
2004, the British National Health Service (NHS) permitted its
doctors to prescribe maggot therapy. Patients no longer have to be
referred to one of a few regional wound-specialty hospitals to get
The BioTherapeutics, Education & Research Foundation was established
in 2003 for the purpose of supporting patient care, education, and
research in maggot therapy and the other forms of symbiotic medicine
(diagnosing and/or treating diseases with live animals, such as
maggot therapy, leech therapy, honey bee therapy, pet therapy &
sniffer dogs, ichthiotherapy, bacteriotherapy etc).
Biology of flies and
Maggots are fly larvae, or immature flies, just as caterpillars are
butterfly or moth larvae. Maggots do not appear all by themselves
("de novo"), as was believed 150 years ago; they hatch from eggs,
laid by adult female flies.
Not all species of flies are safe and effective as medicinal
maggots. There are thousands of species of flies, each with its own
habits and life cycle. Some fly larvae feed on plants or animals, or
even blood (i.e., mosquitoes). Others feed on rotting organic
Those flies whose larvae feed on dead animals will sometimes lay
their eggs on the dead parts (necrotic or gangrenous tissue) of
living animals. When maggots are infesting live animals, that
condition is called “myiasis.” Some of those maggots will feed only
on dead tissue, some only on live tissue, and some on live or dead
tissue. The flies used most often for the purpose of maggot therapy
are "blow flies" (Calliphoridae); and the species used most commonly
is Phaenicia sericata, the green blow fly.
A diagram and photograph of a typical blow fly life cycle appears
(used with permission of the BTER Foundation)
Advantages and disadvantages of maggot
debridement therapy (“MDT")
Efficacy, as demonstrated in several small but
significant controlled clinical studies.
Takes about 15-30 minutes to apply a secure dressing
to keep the maggots in place.
Excellent safety record.
Maggots are highly perishable and should be used
within 24 hours of arrival.
Simple enough that non-surgeons can use it to
provide thorough debridement when surgery is not available or is not
the optimal choice. This means that it is also possible to provide
surgical quality debridement as an outpatient or in the home.
Low cost of treatment.
Common misconceptions about
|“Patients would not
want maggots on them”
||What patients do not
want is a stinking, draining wound. What patients do not want
is to lose their foot. What patients do not want is 4 more
weeks of a treatment in which they do not see any benefit. To
someone with a non-healing wound, wearing “baby flies” for 2
days is not too high a price to pay, if the potential for
success is what is reported with MDT.
|“It might not be
possible to get out all the maggots after treatment”
||The maggot dressing
is removed as soon as the maggots have finished secreting
their proteolytic (tissue-dissolving) enzymes (within 48-72
hours). At that time, their natural instinct is to leave the
wound and crawl away as quickly as possible. So when the
dressing is opened, the maggots will be “at the gate,” eagerly
awaiting their release. If any slow growing larvae remain,
they can be removed with a simple wipe, wash, or irrigation.
|“If one of the
maggots is left in, it might bury itself in the tissue or
||If any maggot is
overlooked (for example, it was slow growing, and hid in the
recesses of the wound when the dressing was opened), it will
continue to feed on the dead tissue of the wound only as long
as dead tissue is present, and probably only for a maximum of
12-24 hours. Medical grade maggots do not bury in or feed on
healthy tissue. What’s more, they are obligate air-breathers.
Therefore, they must remain where there is air, and they will
leave the body as soon as they are finished feeding or as soon
as there is no more dead, infected tissue left.
are sterile, so they can not reproduce or turn into flies”
maggots are often called “sterile maggots,” but the use of the
word “sterile” means germ-free. They are best called
“disinfected maggots.” They can mature into flies (although it
will take them about 3 weeks, and they can then reproduce.
However, all larvae are immature, and can not reproduce until
might reproduce in the wound, making even more maggots”
||Not true. Larvae of
all species are immature, and can not reproduce.
are no longer available”
||Medical maggots are
readily available from several sources, in many countries. See
below for a list of suppliers.
and private insurance will not cover maggots or maggot
||In the U.S., maggot
therapy should be coded with an appropriate procedure code for
“selective debridement without anesthesia” (i.e., CPT codes
97597 or 97598) or a CPT code for misc. skin procedures (i.e.,
17999). While it is true that CMS declined to issue a national
code (HCPCS code) for the maggots themselves, they can and
should be billed as an additional expense, and will generally
be covered by private and governmental third-party payers.
When billing for the maggots themselves, consider using either
the ABC code for maggots (EAACT) or the HCPCS code for misc.
Appeal may be necessary. The BTER Foundation will assist with
appeals. For those without financial resources, the BTER
Patient Assistance Grants. Additional information can be
found in the recent press release by the BTER Foundation.
might hurt if the maggots bite me”
||Maggots do not bite.
They do not have teeth. They do have modified mandibles
though, called “mouthhooks,” and they have some rough bumps
around their body which scratch and poke the dead tissue, one
of the mechanisms that debrides the wound. It is similar to a
surgeons “rasper,” but on a microscopic scale. The maggots are
so small when applied that they can not even be felt within
the wound. Those patients who already have wound pain before
beginning maggot therapy, perhaps due to exposed nerves or
other reasons, may have some pain during maggot therapy when
the maggots become large enough to be felt crawling over those
nerves (usually at about 24 hours). Those patients should be
given access to pain medications (analgesics); but if pain
medication is inadequate to relieve the discomfort, the
maggots can be removed early. Once the dressings are removed,
the maggots will crawl out and the pain should cease
immediately. If further debridement is necessary, another MDT
dressing can always be applied later, but it should be used
only for a brief period, again, until the patient is
maggots are cheap; but garbage maggots are even cheaper, and
should be just as good”
||While it is true
that the species used to make medical grade maggots are found
in the wild, so too are thousands of other species; and not
all species are safe and effective. In fact, the literature
suggests that not all strains of the same species are equally
safe and effective. What’s more, wild maggots may carry
pathogens even more harmful than the ones already on the
wound. Therefore, it is prudent to use medical grade maggots
that have been demonstrated to be disinfected (germ-free),
safe, and effective.
for health care providers
Medicinal maggots have three actions: 1) they debride (clean) wounds
by dissolving the dead (necrotic), infected tissue; 2) they
disinfect the wound, by killing bacteria; and 3) they stimulate
In the U.S., indications listed on the package insert include: “. .
. debriding non-healing necrotic skin and soft tissue wounds,
including pressure ulcers, venous stasis ulcers, neuropathic foot
ulcers, and non-healing traumatic or post surgical wounds.”
There are many reports about maggot therapy also being used for
other wounds, suck as burns, osteomyelitis, fasciitis, clean but
non-healing wounds . . . but these are not currently approved
indications for any medicinal maggots currently on the market.
The BTER Foundation, in collaboration with community leaders,
drafted a MDT Policies & Procedures template for hospitals and
clinics to use when writing policies for their facility. The
template is available for free download.
For more details about the specific application procedures, readers
are referred to the manufacturer's directions. A list of
manufacturers can be found elsewhere on
The BioTherapeutics, Education and Research (BTER) Foundation has
produced a workshop to train health care providers in the Principles
and Practice of Maggot Therapy. The workshops are held in cities
across the U.S., as invitations and co-sponsors present themselves.
Participants learn the indications, contraindications, and
techniques of maggot therapy during this 6-hour didactic and
practical ("hands-on") training workshop.
For more information about the curriculum and the upcoming
workshops, visit the MDT Workshop Website or contact the
Information for patients
Maggot therapy is an effective, accepted method of treating chronic,
non-healing wounds. Only specially selected, tested, disinfected
larvae are applied to the wound surface and covered with a dressing
that prevents the larvae from escaping. They are easily and
completely removed 2 or 3 days later. Sometimes the wound is
completely cleaned by then; sometimes additional treatments may be
necessary. After maggot therapy, the wound may be clean enough to
close, cover, graft, or flap. Your doctor will be able to suggest
the best treatment to follow.
If you do not have insurance, Medicare or Medicaid, and if you do
not have the financial means to cover the cost of treatment, ask
your doctor to provide the service at a reduced fee, and apply for a
Patient Assistance Grant from the
Foundation to cover the cost of the maggots.
How to find a therapist
If you are looking for a therapist to evaluate your wound for maggot
therapy, first ask your current physician or surgeon. S/he knows you
already, and can provide local care and follow-up. The procedure is
simple enough that most licensed therapists can do it with ease.
Courses are available (see
Foundation) and your current doctor or wound care therapist may
have already had experience.
If that is not possible, or if your therapist would like to speak
with others who have more experience, a list of referrals and
consultants can be found at
www.ucihs.uci.edu/som/pathology/sherman/mdtists1.htm. Also, try
contacting your local supplier of medicinal maggots for a referral.
Frequently asked questions
|How do you keep the
maggots on the wound?
||Because the natural
tendency of the maggots is to wander off before and after they
have finished feeding, they must be kept in place by dressings
that allow air to enter, allow liquefied necrotic tissue to
drain out, and still keep the maggots securely over the wound.
This can be done with a porous, mesh-like covering (i.e.,
nylon netting) affixed to the wound border (by tape, or glued
to a hydrocolloid pad). It is removed 48-72 hours later, and
the maggots removed.
|How do you get all
of the maggots out?
||Once the dressing is
removed, all of the maggots should crawl out of the wound and
away from the host because they will be satiated and ready to
migrate. Remaining maggots can be wiped off with a wet gauze
pad. If there are any young larvae still there that you can
not remove, simply cover the wound with moist gauze and
replace it three time/day; the remaining maggots will leave
the wound and bury themselves in the gauze within 24 hours.
|How do I dispose of
the maggot dressings?
germ-free when applied, but become contaminated when they come
into contact with the patient’s wound flora. Therefore, MDT
dressings should be handled like all other infectious dressing
waste. Place the maggot dressings in a plastic bag and seal
the bag completely. Then place the sealed bag into a second
plastic bag and seal completely. Place the bag with the other
infectious dressing waste in an appropriate infectious waste
bag and autoclave or incinerate within 24 hours, according to
waste management policies.
|How do I dispose of
||Unused maggots are
germ-free. They may be discarded in regular trash bins. Seal
their vial so that they can not escape.
|How many treatment
cycles are necessary?
||The number of
treatment cycles depends on the size of the wound and the
ultimate goal of treatment (debridement, wound preparation for
graft, or wound closure). The average course is 2-4 cycles.
Examine the wound after treatment (and 24 hours later, if
possible), to determine if another treatment is necessary.
|Does maggot therapy
||For those few
patients who feel wound pain, they will likely also feel pain
or discomfort with maggot therapy as the maggots become large
enough to feel (about 24-36 hours into the treatment cycle.
Use analgesics liberally, and remove the dressings if/when
analgesics fail to control pain. The pain will abate
immediately after the dressing is removed.
Producers and distributors
of medical-grade maggots
|United States /
17875 Sky Park Circle, Suite K
Irvine, CA 92614
UK and Continental Europe
Phone: +49 (0)40 6710 57-0
Jose Contreras Ruiz
e-mail: firstname.lastname@example.org or
Units 2-4 Dunraven Business Park
Tel: 0845 2301810
Fax: 01656 668047
Japan Maggot Company
Hideya Mitsui, MD
Assistant Professor of surgery
Department of vascular Surgery
Okayama University Medical School
2-5-1 Schikata Okayama city,
Dr. Tarek I. Tantawi
Department of Zoology
Faculty of Science
Moharrem Bey, Alexandria
Medilarvatech Co. Ltd. Korea
Suite 909-3, Dogock-dong, Kangnam-gu,
Phone : 82) 02-576-6340
Fax : 82) 02-579-5278
Dr. Kosta Mumcuoglu
Department of Parasitology
Hebrew University - Hadassah Medical School
PO BOX 12271, 91120
Phone: + 972-2-675-8093
Fax: + 972-2-675-7425
Merilyn Geary, Laboratory Director
Department of Medical Entomology
Westmead NSW 2145
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20;318(7186):807-8. PMID: 10082718
Vistnes LM, Lee R, Ksander GA. Proteolytic activity of blowfly
larvae secretions in experimental burns. Surgery. 1981
Nov;90(5):835-41. PMID: 7029766
Wayman J, Nirojogi V, Walker A, Sowinski A, Walker MA. The cost
effectiveness of larval therapy in venous ulcers. J Tissue
Viability. 2000 Jul;10(3):91-4. Erratum in: J Tissue Viability 2001
Jan;11(1):51. PMID: 11299572
Wolff H, Hansson C. Larval therapy--an effective method of ulcer
debridement. Clin Exp Dermatol. 2003 Mar;28(2):134-7. PMID: 12653696
Wolff H, Hansson C. Larval therapy for a leg ulcer with methicillin-resistant
Staphylococcus aureus. Acta Derm Venereol. 1999 Jul;79(4):320-1. No
abstract available. PMID: 10429993
Wollina U, Kinscher M, Fengler H. Maggot therapy in the treatment of
wounds of exposed knee prostheses. Int J Dermatol. 2005
Oct;44(10):884-6. PMID: 16207200
Wollina U, Liebold K, Schmidt WD, Hartmann M, Fassler D. Biosurgery
supports granulation and debridement in chronic wounds—clinical data
and remittance spectroscopy measurement. Int J Dermatol. 2002
Oct;41(10):635-9. PMID: 12390183
Internet site specializing in maggot therapy:
BioTherapeutics, Education & Research Foundation at
University of California, Irvine, Maggot Therapy Project at
Arrange to attend or sponsor a Maggot Therapy Lecture or Workshop
Press articles and internet postings:
(copy and paste link into your browser)
CBS Channel 2 TV News story on maggot therapy (11/07/06), with video
CNN Online (10/20/97) at: http://www.cnn.com/HEALTH/9710/20/maggot.therapy/
Public Broadcasting Corporation at:
The Augusta Chronicle Online, 7/23/97 at: http://augustachronicle.com/stories/072497/tech_maggot.html
Australin Broadcasting Corporation / Great Moments in Science, EP
14, 1998 web site at: http://www.abc.net.au/science/k2/moments/gmis9814.htm
BBC News (Doctor! There's a maggot in my wound; 3/6/99) at: http://news.bbc.co.uk/hi/english/health/newsid_291000/291331.stm
BBC News (Maggot Cure for 'Unbeatable' Bug; 3/19/99) at: http://news.bbc.co.uk/hi/english/health/newsid_299000/299174.stm
BBC News (Maggot medicine gains popularity; 4/6/02) at: http://news.bbc.co.uk/hi/english/health/newsid_1907000/1907065.st
Maggot debridement therapy promising; by: Rochelle Nataloni (Mar 1,
2004) at: http://www.dermatologytimes.com/dermatologytimes/article/articleD
Maggots and leeches: Good medicine By Rita Rubin, USA TODAY, at:
Tiny surgeons: Maggot therapy clears the dead tissue cleanly
Tuesday, July 13, 2004 By Christopher Snowbeck, Pittsburgh
Post-Gazette at: http://www.post-gazette.com/pg/04195/345382.stm
Leeches, maggots and parasitic worms can play healing role By Carol
M. Ostrom; Seattle Times staff reporter (Wednesday, August 04, 2004)
Maggots find new role in medicine By: Rallie McAllister, M.D.,
M.P.H.; GoTriCities Wellness at: http://www.gotricities.com/wellness/article.dna?idNumber=050221110937
Grubs up. By Hugh Wilson; The Independent (1, March, 2005) at:
Sherman RA: Maggot Therapy in Modern Medicine. Infections in
Medicine. 15(9): 651-656. 1998; on the WWW for Medscape users, at: