CLINICAL FOCUS

Maggots and their role

in wound care
Julie Jones, Julie Green and Alison Kate Lillie

Julie Jones, written during final year of B.Sc (Hons) Adult Nursing, Julie Green, Lecturer in Nursing, Keele University, Alison
Kate Lillie, PhD Lecturer in Nursing, Keele University
Email: juliejonesxxxx@yahoo.co.uk

hronic wounds can be defined as those which do

not heal progressively through a set of particular
stages, hence failing to provide an anticipated
recovery time. Many chronic wounds still require treatment after three months has lapsed (Ayello and Cuddigan,
2004; Benbow, 2007). These chronic wounds place a huge
burden upon the already stretched resources of the NHS,
especially where such wounds present as chronic venous
leg ulcers (Harding et al, 2002).
Leg ulcers caused by chronic venous insufficiency affect a
great many of the population; approximately 1-2 people out
of every 1000 of people at any one time; with around 10-20
people out of every 1000 experiencing this at least once
(Bergan et al, 2006; Posnett and Franks, 2008). Ulcer healing
rates are notoriously poor; with around 50% still remaining
unhealed and requiring ongoing treatment some 9 months
after diagnosis. Recurrences are common; with one third
of those currently being treated suffering their fourth or
more event. (Bergan et al, 2006). This being the case, 1.3%
of the whole healthcare expenditure is concentrated on
ulcer management in the UK, with 90% of those affected
being treated within the community setting. The total cost
each year to the NHS is estimated within the region of
200 million per year (Posnett and Franks, 2007).
The primary purpose of maggot therapy is the breakdown of necrotic tissue within a chronic wound, which will

Abstract

Leg ulcers caused by chronic venous insufficiency affect a great many

of the population, costing the NHS an estimated 200 million per year.
The clinical use of sterile maggots under the brand name LarveE has
increased steadily in the UK since they were introduced in the UK in
late 1995. Maggot therapy breaks down necrotic tissue within a chronic
wound, transforming it into an acute wound; subsequently beginning
the healing process a lot quicker, thus reducing overall costs to the
National Health Service. A literature review was conducted on studies
that explored the use of maggot therapy in the management of chronic
wounds. Four key themes were identified and analysed from this search,
including infection control, promotion of healing, cost-effectiveness and
the yuk factor.

KEY WORDS
w Larval therapy w Maggot therapy w Chronic wounds w Leg ulcers w

Wound debridement w Infected wound management

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then transform into an acute wound; subsequently beginning the healing process a lot quicker. Over time, this will
reduce overall costs to the NHS; which is a constant goal
(Courtenay et al 2000; Mumcuoglu, 2001; Sherman, 2003).
Maggot therapy is not a new discovery; it has been
known to be conducive to effective wound management
for many years; albeit initially accidental infestations (Jones
and Andrews, 1998); with subsequent military use dating back to Napoleonic times. Today, this treatment has
a growing popularity and specially constructed laboratories owned by companies such as BioMonde (formerly
ZooBiotic) Ltd. based in Brigend, South Wales, who
regularly supply sterile larvae to NHS trusts all over the
UK (BioMonde, 2010).
Maggot applications are provided in two different
preparations. The BioFOAM dressing is a woven net bag,
containing a number of maggots each a few millimetres
long. These are available in varying sizes, depending upon
demands of the wound. BioFOAM dressings contain
products that support and stimulate maggot activity, while
containing exudates (Figure 1). These are then held in place
with a secondary dressing.
The maggots are also available free-range, whereupon
they are supplied in a clear container and placed directly
onto to wound (Figure 2), which is then covered with
a fine mesh or stocking (depending upon the extent of
the wound) with some adhesive around the outer edge
to secure the dressing. The wound should be measured
and a larvae calculator used to order the correct amount
(BioMonde, 2010; Knowles et al, 2002).
Despite maggot therapy gaining in popularity, and being
deemed a highly efficient method of chronic wound debridement, it still remains cosmetically unappealing to the
majority of patients and nursing staff (Thomas and Jones,
2000). While maggot therapy is accepted and adopted as a
one of the best debridement techniques for future management of chronic wounds (Sherman, 2005), many areas
for improvement surrounding maggot therapy were identified via analysis of literature on the subject.

Literature search
Search strategy

A search strategy was used to identify both empirical and

theoretical literature using the aforementioned keywords;
larval therapy, maggot therapy, chronic wounds, leg ulcers
and infected wound management.This search encompassed

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Figure 1. BioFOAM dressings contain products that support and stimulate

maggot activity, while containing exudates

field of wounds, such as BioMonde, Smith and Nephew

and World Wide Wounds. This was achieved through an
accumulation of postal correspondence, emails and internet
access to their corresponding websites; which allowed the
authors to gather information relating to the clinical production and use of sterile larvae in chronic wound therapy.
Specialist practitioners such as the tissue viability nurses
(TVNs) and wound care representatives via the community
setting have also been contacted, to provide further supporting information and evidence.

Search results

Figure 2. Maggots are available free-range, they are supplied in a clear

container and placed directly onto to wound

Table 2 lists the numbers of results gained from the varying internet sources. The total number of articles accessed
using the search strategy prior to applying the inclusion/
exclusion criteria was 106. However, once this was applied,
the number was reduced to 7 articles that were appropriate
for reviewing.
A well-established critiquing tool; Critical Appraisal
Skills Programme (CASP) has then been used to critique
the research collated, via a framework devised of questions
that are asked and serve to test/ascertain the robustness of
the studies and establish whether the findings from the
studies were appropriate and thus applicable to clinical
practice for future impact (Public Health Resource Unit
(PHRU), 2006).
Four key themes were identified and analysed from this
search, including infection control, promotion of healing,
cost effectiveness and the yuk factor.

Infection control

books, internet, and electronic sources to ensure only the

most up to date, relevant information was accessed.
Relevant databases were selected and searched; those
being British Nursing Index, CINAHL, EMBASE,
MEDLINE,The Cochrane Library and GOOGLE Scholar.
The following search words were used: Chronic
wounds, Larval therapy, Maggot therapy, Leg ulcer,
Wound debride, Wound manage.
Additional data was also collated via hand-searching relevant journals at the Keele University Clinical Education
Centre, and via reference list/author searching. In addition,
supporting evidence has been gathered from experts in the

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Chronic wounds are notoriously prone to infections such

as Methicillin-resistant Staphylococcus aureus (MRSA) or
other hospital acquired pathogens such as Pseudomonas,
and the resulting aggressive long, drawn out treatment with
antibiotics and topical applications, and the isolation of the
patient who may contract further infection, can incur great
costs for care, bed days and nurses time (Beasely, 2004).
However, maggots are known to secrete proteolytic
enzymes including collagenase (Ziffren et al, 1953) and
enzymes resembling trypsin and chymotrypsin (Chambers,
2003), which aid absorption of dead tissue and bacteria;
where the bacteria is then destroyed as it passes through
their digestive system (Steenvoorde, 2005). With this in
mind, but also the knowledge that much evidence is considered anecdotal or only that contained in case reports
(Courtenay, 1999; Dissemond, 2002), a number of studies have been carried out that have confirmed that all
micro organisms were eradicated within 10-15 minutes of
ingestion by the maggot (Robinson and Norwood, 1934;
Simmons, 1935; Lappin-Scott, 1998; Mumcuoglu et al,
2001).
A further study by Courtenay et al (2000) concluded that
maggot therapy is an extremely efficient alternative option
for fast and efficient wound management, often preventing major surgery, and an excellent ally in the fight against
antibiotic-resistant infection. All the literature reviewed in

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Table 1. Inclusion/exclusion criteria

Table 2.

Inclusion criteria

Exclusion criteria

Database

Research available in
English

Research not available in English

Number of articles

British Nursing Index

11

Published since 1995

Research prior to
1995

CINAHL

45

Adult patients aged 18+

Paediatric patients

EMBASE

15

Chronic wounds

Acute wounds

MEDLINE

Primary care focus

Secondary care
focus

The Cochrane Library

12

Google Scholar

Published research

Unpublished
research

Pubmed

15

this section indicated that maggot therapy was not only

instrumental in reducing bacteria levels, thus infection, but
also in reducing unpleasant odours and pain (Robinson
and Norwood, 1934; Simmons, 1935; Lappin-Scott, 1998;
Courtenay et al, 2000; Steenvoorde et al, 2007).

Promotion of healing
A chronic wound is one which is non-healing and often
incorporates bacteria-laden slough, which has to be debrided if the wound is to heal (National Institute for Health
and Clinical Excellence (NICE), 2001; Cutting et al 2002;
Ayello et al 2004). Wound healing is a complex biological
process, and it is imperative that all clinicians involved in
wound care, understand the process which prevents, minimizes and eliminates factors which adversely effect wound
healing (Cutting et al, 2002).
Wound healing includes four stages; haemostasis, inflammation, proliferation and maturation, occurring independently and simultaneously (University Hospital of North
Staffordshire (UHNS) 2001; Wound Care Formulary, 2001;
Shipperely and Martin, 2002; Timmons, 2006). Maggot
therapy is considered to be instrumental in the breaking
down of necrotic tissue in chronic wounds, and encourages
healthy, granulating tissue in wound beds (Sherman, 2003;
Acton, 2007; BioMonde, 2010).
To investigate this theory, a key study by Dumville et al
(2009), called the VenUS II Trial, was carried out, which
had two main objectives:
w To assess the clinical effectiveness of maggot therapy in
comparison to hydrogel, a standard debridement treatment
w To assess the clinical effectiveness of loose maggots in
comparison to bagged maggots
This pragmatic, three-armed randomized controlled
trial (RCT) compared loose maggots, bagged maggots
and hydrogel, and involved 267 patients with venous or
mixed aetiology ulcer wounds, each with a 25% sloughy
area/necrotic tissue. The study concluded that overall maggot therapy proved to be no more effective in reducing
bacterial load or improve healing rates within sloughy or
necrotic ulcers when compared with hydrogel, but it did
appear to improve debridement times. However, ulcer pain

S28

experienced by the participants did appear to increase.

Despite this study having several limitations, the sample
size was relatively large in comparison to other studies,
which supports generalizability and reliability of the findings (Cormack, 2000).
A further study by Sherman (2003) also established the
efficiency of maggots as a debridement technique, which
supports findings from the VenUS II Trial. However, the
sample was notably small and thus did not support generalizability and reliability of the findings, which may be
deemed a limitation (Cormack, 2000).
All literature reviewed in this section indicated that
maggot therapy did indeed hasten debridement of necrotic tissue from chronic wounds, and encouraged swift
granulation in comparison with conventional treatments,
culminating in greatly improved chronic wound healing
(Sherman, 2003; Acton, 2007; BioMonde, 2010).

Cost-effectiveness
Approximately 200 000 people each year in the United
Kingdom suffer from chronic wounds at any one time,
costing the NHS in excess of 2.3bn3.1bn per year to
care for them (Posnett and Franks, 2008). As a result, a
number of studies to assess the cost effectiveness of maggot therapy in comparison to conventional treatments have
been undertaken (Thomas, Banks, and Bale, 1997).
One study in particular conducted by Wayman et al
(2000), involved 12 patients with venous ulcers that were
sloughy. All the patients were allocated to either the maggot
therapy group or alternatively the hydrogel therapy group.
The participants were observed up until debridement had
occurred, or up to a maximum of a month. Results showed
that some patients had achieved debridement in just one
application of maggot therapy, while in contrast; some of
those receiving the hydrogel treatment were still requiring
dressings one month later.
The cost implication proved greater with the hydrogel
treatment, which was found to be 136.23, compared to
78.64 for the maggot therapy patients. However, the true
cost can only be measured once the number and frequency
of nursing visits in addition to the cost of treatments has
been established. It was also recognized that despite the
fact that the randomization supported validity/reliability,
the study was not blinded and therefore open to bias,

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and in addition to this the small sample size rendered the

study questionable of generalizability (Cormack, 2000).
However, Wayman et al (2000) does acknowledge these
limitations, and recognized the need for a larger study.
Following the review of cost-effectiveness literature,
while a single application of maggot therapy may initially
be more costly than the hydrogel, results indicate that
reduced healing time, nursing visits and applications within
the maggot therapy group contributed to less cost overall,
suggesting that maggot therapy may ultimately be more
cost effective than standard debridement treatments.

The yuk factor

Just mentioning word maggots generates repugnant images of infested, rotting food, or worse still, decaying flesh,
so it is not surprising that the thought of placing these
creatures on infected wounds is often an unattractive and
unbearable consideration for many patients suffering with
chronic wounds. This is deemed the yuk factor (Evans,
2002; Sherman, 2003).
There is limited literature on patient experiences of
maggot therapy, and so to try and determine the extent
of this yuk factor, Kitching (2004) carried out a phenomenological study on 6 patients over a 12-week period
suffering from severe symptoms related to their chronic
wounds. Despite patients initial misgivings and negative
preconceived ideas surrounding maggot therapy; those
being that they are dirty creepy crawlies, crawling inside
their wound, and one patient even requesting a general
anaesthetic while having treatment.
Following the provision of clear information and subsequent therapy, five out of six patients were pleasantly surprised that it was not as unpalatable as they had suspected
it to be, and that their wounds had improved overall with
very little or no pain (Kitching, 2004).
Kitching (2004) acknowledged the limitations in the
study being of uneven sampling, with a ratio of 5:1,
women to men, and while being a very small sample of six,
which limits validity (Cormack, 2000). However, Kitching
concluded that the study did appear to establish that providing all negative issues surrounding maggot therapy are
addressed with each patient, then it may no longer prove
unacceptable to them (Kitching, 2004).
A later study by Steenvorde (2005) supported these

S30

findings, which was centred upon 41 patients with nonhealing wounds in hospital in the Netherlands. Following
treatment, out of the 37 that returned questionnaires, none
expressed a negative response towards maggot therapy, and
said furthermore, that they would recommend it to others.
As there exists a similarly up-to-date provision of medical
care, this can be judged as generalizable globally.
These results also echoed an earlier study by Courtenay
(1999), extending to 23 hospitals throughout the UK.
In this study a qualitative approach was adopted, with
the collection of documentary evidence and data from
semi-structured interviews. After liaising with nurses and
patients at each one, Courtenay (1999) concluded that
those with little or no prior experience/knowledge of
maggot therapy were the more reluctant to contemplate
initiating the treatment, and considered it a last option,
while those with prior experience/knowledge embraced
the notion of implementing maggot therapy into their
patients wound treatment regime.
From the literature reviewed in this section, support,
guidance and training in maggot therapy was flagged up as
instrumental in eliminating the so called yuk factor, the
provision of up-to-date, honest information regarding the
processes involved and perceived outcomes of the therapy,
encouraging more practitioners/patients to be accepting of
maggot therapy. In such instances nurses can greatly influence patient choice with good quality information and
honest communication (Courtenay et al, 2000; Thomas,
2001; Jukema et al, 2002; Sherman, 2003).

Conclusion and recommendations

There is a common opinion that much more research is
needed in this area (Thomas et al, 2003; White 2005), as
clinical trials involving maggot therapy are somewhat limited, and now, more than ever, evidence warrants further
investigations (Sherman, 2002), particularly in view of the
fact that qualified practitioners rely heavily upon clinical
trials to provide the evidence base which rationalizes their
adoption and use of new treatments and interventions
(Venlcatramam et al, 2002).
Improved clinical trials are needed to assess the effectiveness of maggot therapy while treating all chronic wounds,
including pressure ulcers, venous stasis ulcers, diabetic foot
ulcers, burns and post-surgery wounds, when compared to

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key points

w
The conservative treatment of chronic wounds currently costs the NHS in
the region of 200 million per year.
w
Maggot therapy has been shown to dramatically reduce healing time and
overall costs associated with chronic wound management.
w
Further research is suggested to support and encourage greater use of
maggot therapy within the clinical environment.
w
Improved training and education for practitioners and patients is required
to challenge barriers associated with maggot therapy, i.e. the yuk factor.

conservative medical treatments and surgical debridement.

Moreover, RCTs are considered to be gold standard in
terms of research, and in demonstrating the effectiveness
of a particular treatment/intervention in a very rigorous,
scientific approach (Cormack, 2000; NICE, 2000).
Further studies to ascertain the overall cost effectiveness
of maggot therapy will also be invaluable, to establish the
optimum time scale of use of maggot dressings, and also
the impact of maggot therapy on infection control issues,
i.e. the avoidance/reduction of wound infections such as
MRSA, possibly culminating in the need for antibiotics
and analgesia, and avoidable, costly hospital admissions.
The statistics from studies such as these and those reflecting
the current extent and cost of caring for patients chronic
wounds, will serve to support and encourage the drive to
discover swift and effective wound healing methods, which
will undoubtedly reduce the present burden upon health
professionals and the NHS in general (NICE, 2000).
A need is also recognized for more qualitative studies, to
establish if a negative preconceived image of maggot therapy, namely the yuk factor, indeed has a detrimental effect
upon the patient or qualified practitioner when deciding
upon a wound management strategy. Further studies will
also ascertain whether a negative attitude towards maggot
therapy held within the clinical environment has greater
far-reaching effects, in that it actually prevents promotion
of the therapy altogether. It is believed that more detailed
qualitative studies could substantially improve acceptability
levels of maggot therapy (Mumcuoglu et al, 2001).
Education and training for staff surrounding maggot
therapy is considered essential in order to break down
these barriers associated with the yuk factor. One of the
greatest fears for those contemplating maggot therapy is
that of the maggot possibly turning into a fly while in
the wound. It is imperative, therefore that nurses gain a
full understanding of the life cycle of the maggot in order
to be able to reassure the patient with confidence. Other
information that nurses need to be familiar with include
the mechanism of maggot debridement, the different
applications available, maintenance of the dressing and
possible side-effects associated with the therapy, i.e. tingling sensation, pain, bleeding and increased exudate. It is
imperative that the nurse is knowledgeable in order to pass
on this information and gain full consent from the patient.
Of course a great deal more knowledge can be absorbed
with proper education. However, it would be extremely

S32

costly to train all qualified nurses on a one-to-one basis, and

so it is suggested that the cascading of information by suitably trained link nurses and use of company nurse advisors
may be a route to follow. In addition, explicit, informative
leaflets could be made available for all nurses, and specially
trained TVNs could be the ones to actually suggest and initiate the treatment, and then be available to offer advice and
guidance to nurses and patients alike, regarding all aspects of
maggot therapy as the treatment progresses.
In addition, modified information leaflets could be distributed to patients themselves considering maggot therapy,
which address many key issues relating to the patients
experience of maggot therapy as we know it, i.e. the different modes of application, reassurance that the maggots will
not lay eggs or burrow healthy tissue, possible side effects,
and that the patient can continue pretty much with his or
her normal routine. Leaflets provided by a trusted supplier
of the larvae such as BioMonde would serve to ensure
consistency of information to patients and thus serve to
alleviate some of the stress and concerns that the patient
may be feeling. In addition, the TVN involved in their
treatment can further reassure and support the patient in
their decision making.
Ultimately, a push for more RCTs (a number of which
are currently being undertaken, although the development
of which can be difficult) to establish the appropriateness
of maggot therapy for use in the clinical environment,
such as the well known VenUSII trial (Dumville, 2009), its
cost effectiveness and its safety and quality, combined with
education and evidence-based practice, will support and
encourage the inclusion of maggot therapy in the drug
tariff. This would potentially result in it being more readily
and widely prescribed in the future, as it could be argued
that a drug tariff without a full spectrum of products compromises the care of patients (Millard, 2002).
To conclude, the above recommendations are considered
to be basic and achievable within our current NHS environment, with any initial costs incurred almost certainly
recuperated quickly with the growing use of maggot therapy and thus costs saved by the divergence from alternative,
more expensive treatments. The implementation of these
recommendations will serve to promote maggot therapy
as the cost-effective, efficient, patient-friendly method of
chronic wound management that it is proven to be, so that
it can be widely adopted as a safe, efficient, contributor to
chronic wound healing.
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