Larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential

When modern medicine fails, it is often useful to draw ideas from ancient treatments. The therapeutic use of fly larvae to debride necrotic tissue, also known as larval therapy, maggot debridement therapy or biosurgery, dates back to the beginnings of civilisation. Despite repeatedly falling out of favour largely because of patient intolerance to the treatment, the practice of larval therapy is increasing around the world because of its efficacy, safety and simplicity. Clinical indications for larval treatment are varied, but, in particular, are wounds infected with multidrug-resistant bacteria and the presence of significant co-morbidities precluding surgical intervention. The flies most often used in larval therapy are the facultative calliphorids, with the greenbottle blowfly (Lucilia sericata) being the most widely used species. This review summarises the fascinating and turbulent history of larval therapy from its origin to the present day, including mechanisms of action and evidence for its clinical applications. It also explores future research directions.

[1]  G. Dunbar.  Notes on the Ngemba Tribe of the Central Darling River, Western New South Wales , 2009 .

[2]  Michael T Longaker,et al.  Progress and potential for regenerative medicine. , 2007, Annual review of medicine.

[3]  G. Maddern,et al.  The safety and efficacy of topical negative pressure in non-healing wounds: a systematic review. , 2006, Journal of wound care.

[4]  I. Gould,et al.  The clinical significance of methicillin-resistant Staphylococcus aureus. , 2005, The Journal of hospital infection.

[5]  J. Dumville,et al.  A new clinical trial of the effect of larval therapy. , 2004, Journal of tissue viability.

[6]  K. Shakesheff,et al.  Maggots and wound healing: an investigation of the effects of secretions from Lucilia sericata larvae upon interactions between human dermal fibroblasts and extracellular matrix components , 2003, The British journal of dermatology.

[7]  C. Hansson,et al.  Larval therapy – an effective method of ulcer debridement , 2003, Clinical and experimental dermatology.

[8]  R. Sherman,et al.  Maggot therapy for treating diabetic foot ulcers unresponsive to conventional therapy. , 2003, Diabetes care.

[9]  D. Pritchard,et al.  Degradation of extracellular matrix components by defined proteinases from the greenbottle larva Lucilia sericata used for the clinical debridement of non‐healing wounds , 2003, The British journal of dermatology.

[10]  R. Nuesch,et al.  Clustering of Bloodstream Infections during Maggot Debridement Therapy Using Contaminated Larvae of Protophormia terraenovae , 2002, Infection.

[11]  L. Dossey.  Maggots and leeches: when science and aesthetics collide. , 2002, Alternative therapies in health and medicine.

[12]  A. Pfleiderer,et al.  The use of maggots in head and neck necrotizing fasciitis , 2002, The Journal of Laryngology & Otology.

[13]  D. Bonn.  Maggot therapy: an alternative for wound infection , 2000, The Lancet.

[14]  J. Wayman,et al.  The cost effectiveness of larval therapy in venous ulcers. , 2000, Journal of tissue viability.

[15]  U. Wollina,et al.  Biosurgery in wound healing – the renaissance of maggot therapy , 2000, Journal of the European Academy of Dermatology and Venereology : JEADV.

[16]  N. Namias,et al.  Biodebridement: a case report of maggot therapy for limb salvage after fourth-degree burns. , 2000, The Journal of burn care & rehabilitation.

[17]  T. Ryan,et al.  Larva therapy in wound management , 2000, Journal of the Royal Society of Medicine.

[18]  M. Russ,et al.  [Biosurgery - maggots, are they really the better surgeons?]. , 1999, Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen.

[19]  W. Fleischmann,et al.  Biochirurgie – Sind Fliegenmaden wirklich die besseren Chirurgen? , 1999, Der Chirurg.

[20]  C. Hansson,et al.  Larval therapy for a leg ulcer with methicillin-resistant Staphylococcus aureus. , 1999, Acta dermato-venereologica.

[21]  A. Andrews,et al.  The effect of hydrogel dressings on maggot development. , 1999, Journal of wound care.

[22]  R. Sherman,et al.  A new dressing design for use with maggot therapy. , 1997, Plastic and reconstructive surgery.

[23]  P. Prete,et al.  Growth effects of Phaenicia sericata larval extracts on fibroblasts: mechanism for wound healing by maggot therapy. , 1997, Life sciences.

[24]  R. Sherman,et al.  Maggot therapy for venous stasis ulcers. , 1996, Archives of dermatology.

[25]  S. Shutler,et al.  Using larvae in modern wound management. , 1996, Journal of Wound Care.

[26]  Richard P. Lane,et al.  Medical Insects and Arachnids , 1993, Springer Netherlands.

[27]  E. Luce,et al.  The use of maggots in wound debridement. , 1988, Annals of plastic surgery.

[28]  E. Pechter,et al.  Maggot therapy: a review of the therapeutic applications of fly larvae in human medicine, especially for treating osteomyelitis , 1988, Medical and veterinary entomology.

[29]  S. Teich,et al.  Maggot therapy for severe skin infections. , 1986, Southern medical journal.

[30]  G. Erdmann,et al.  Isolation and identification of two antibacterial agents produced by a strain of Proteus mirabilis isolated from larvae of the screwworm (Cochliomyia hominivorax) (Diptera: Calliphoridae). , 1986, Journal of medical entomology.

[31]  J. Bunkis,et al.  Maggot therapy revisited. , 1985, The Western journal of medicine.

[32]  E. Pechter,et al.  Maggot therapy: the surgical metamorphosis. , 1983, Plastic and reconstructive surgery.

[33]  E. Seaquist,et al.  Phormia regina myiasis in a malignant wound. , 1983, Minnesota medicine.

[34]  L. Vistnes,et al.  Proteolytic activity of blowfly larvae secretions in experimental burns. , 1981, Surgery.

[35]  G. Gates,et al.  Maggot therapy for subacute mastoiditis. , 1976, Archives of otolaryngology.

[36]  B. Greenberg.  Model for destruction of bacteria in the midgut of blow fly maggots. , 1968, Journal of medical entomology.

[37]  B. Greenberg,et al.  FLIES AND DISEASE. , 1965, Scientific American.

[38]  E. A. Wright,et al.  An Antibiotic from Maggots , 1957, Nature.

[39]  Pearce Williams,et al.  The Apologie and Treatise of Ambroise Paré Containing the Voyages Made into Divers Places, with Many of His Writings upon Surgery , 1953, The Yale Journal of Biology and Medicine.

[40]  S. K. Livingston.  Clinical results following the use of a surgical jelly containing the maggot active principle , 1938 .

[41]  L. H. Prince,et al.  THE TREATMENT OF CHRONIC OSTEOMYELITIS: WITH SPECIAL REFERENCE TO THE USE OF THE MAGGOT ACTIVE PRINCIPLE , 1932 .

[42]  H. Goldstein.  Maggots in the Treatment of Wound and Bone Infections. , 1931 .

[43]  W. S. Baer,et al.  The Treatment of Chronic Osteomyelitis with the Maggot (Larva of the Blowfly). , 1931 .

[44]  T. File.  Clinical implications and treatment of multiresistant Streptococcus pneumoniae pneumonia. , 2006, Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases.

[45]  R. Sherman,et al.  Medicinal maggots: an ancient remedy for some contemporary afflictions. , 2000, Annual review of entomology.

[46]  J. Church.  The traditional use of maggots in wound healing, and the development of larva therapy (biosurgery) in modern medicine. , 1996, Journal of alternative and complementary medicine.

[47]  F. Wyle,et al.  Maggot therapy for treating pressure ulcers in spinal cord injury patients. , 1995, The journal of spinal cord medicine.

[48]  R. Crosskey,et al.  House-flies, blow-flies and their allies (calyptrate Diptera) , 1993 .

[49]  M. Wainwright.  Maggot therapy--a backwater in the fight against bacterial infection. , 1988, Pharmacy in history.

[50]  E. Chernin.  Surgical maggots. , 1987, Southern medical journal.

[51]  K. Olesen,et al.  IN SPINAL CORD INJURY PATIENTS , 1979 .

[52]  R. D. Shuman.  MYIASIS IN MAN AND ANIMALS IN THE OLD WORLD , 1967 .

[53]  G. Weil,et al.  A biological, bacteriological and clinical study of larval or maggot therapy in the treatment of acute and chronic pyogenic infections , 1933 .

[54]  Es Petherick,et al.  Bmc Medical Research Methodology Open Access Patient Acceptability of Larval Therapy for Leg Ulcer Treatment: a Randomised Survey to Inform the Sample Size Calculation of a Randomised Trial , 2022 .