Maggot debridement
therapy with Lucilia
cuprina: a comparison with
conventional debridement
in diabetic foot ulcers
Aaron G Paul, Nazni W Ahmad, HL Lee, Ashraff M Ariff, Masri Saranum,
Amara S Naicker, Zulkiflee Osman
Paul AG, Ahmad NW, Lee HL, Ariff AM, Saranum M, Naicker AS, Osman Z. Maggot debridement therapy with
Lucilia cuprina: a comparison with conventional debridement in diabetic foot ulcers. Int Wound J 2009;6:
39–46.
ABSTRACT
This is prospective case–control study of more than 18 months performed to assess the effectiveness of maggot
debridement therapy (MDT) with the sterile larvae of Lucilia cuprina (a tropical blowfly maggot) for the
treatment of diabetic foot ulcers. Literature thus far has only reported results with the temperate maggot, Lucilia
sericata. This study documents outcome in diabetic foot wounds treated with maggot debridement versus those
treated by conventional debridement alone. In this series of 29 patients treated with MDT, 14 wounds were
healed, 11 were unhealed and 4 were classified under others. The control group treated by conventional
debridement had 30 patients of which 18 wounds were healed, 11 unhealed and 1 classified under others. There
was no significant difference in outcome between the two groups. The conclusion that can be made from this
study is that MDT with L. cuprina is as effective as conventional debridement in the treatment of diabetic foot
ulcers. It would be a feasible alternative to those at high risk for surgery or for those who refuse surgery.
Key words: Lucilia cuprina  Maggot debridement therapy
INTRODUCTION
Maggot debridement therapy (MDT) has and is
being used extensively in the United Kingdom
(UK) and the United States of America, where
sterile maggots are commercially available. It
has been used as one of the modalities for
the treatment of infected diabetic foot ulcers.
The species used in these temperate climates is
the blowfly Lucilia sericata. Here, in Malaysia,
being a country with tropical weather, we have
the tropical blowfly Lucilia cuprina, instead of
L. sericata. MDT with L. cuprina to our knowl-
edge has never been published. It has been tried
once before here inMalaysia on 12 patients with
diabetic foot wounds at the Lumut Naval
Hospital (1). Two patients in this study had
Key Points
 MDT is as effective as con-
ventional debridement in
treating diabetic foot ulcers.
 MDT with L. cuprina has
similar results to that with
L. sericata
 maggot debridement therapy
(MDT) has and is being used
extensively in the United
Kingdom (UK) and the United
States of America, where
sterile maggots are commer-
cially available
 it has been used as one of the
modalities for the treatment of
infected diabetic foot ulcers
Authors: AG Paul, MD, Department of Orthopaedic Surgery Sarawak General Hospital, Sarawak, Malaysia; NW Ahmad, PhD,
Department of Entomology, Institute for Medical Research, Kuala Lumpur, Malaysia; HL Lee, PhD, Department of Entomology, Institute
for Medical Research, Kuala Lumpur, Malaysia; AM Ariff, MBBS, Institute of Orthopaedics and Traumatology, Hospital Kuala Lumpur,
Kuala Lumpur, Malaysia; M Saranum, BSc(Hons), Department of Entomology, Institute for Medical Research, Kuala Lumpur, Malaysia; AS
Naicker, MD, Rehabilitation Unit, Department of Orthopaedics and Traumatology, Hospital Universiti Kebangsaan Malaysia, Kuala
Lumpur, Malaysia; Z Osman, MD, Institute of Orthopaedics and Traumatology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
Address for correspondence: AG Paul, MD, Surgical Directorate Office, Department of Orthopaedic Surgery Sarawak General
Hospital, 93586 Sarawak, Malaysia
E-mail: a2ronpaul@gmail.com
ORIGINAL ARTICLE
ª 2009 The Authors. Journal Compilation ª 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc  International Wound Journal  Vol 6 No 1 39

MDT discontinued. The other ten had their
wounds heal satisfactorily. This was a descrip-
tive study. We have tried to build on this by
conducting aprospective non randomised case–
control study to prove thatMDTwith L. cuprina
is as effective as conventional debridement in
the treatment of infected diabetic foot ulcers.
Study objective and hypothesis
Our study objective was to compare MDTwith
L. cuprina and conventional debridement for the
treatment of infected diabetic foot ulcers. At this
time of writing, no trials, to the best of our
knowledge, have been published with regards
to the clinical use of L. cuprina.
Our hypothesis is that MDT is as effective as
conventional debridement in the treatment of
infected diabetic foot ulcers.
MATERIALS AND METHODS
Study design
This is a prospective case–control study that
compares two treatment outcomes for diabetic
foot ulcers – conventional debridement and
MDT. This study was approved by the Clinical
Research Centre of the Ministry of Health
Malaysia. Ethics approval was granted to the
Institute of Medical Research, Malaysia (IMR)
for the use of L. cuprina in clinical trials.
Inclusion and exclusion criteria
Inclusion criteria
All patients aged 35–70 years, who were admit-
ted to the orthopaedics wards in the Kuala
Lumpur General Hospital (HKL) for infected
diabetic foot wounds (below ankle) from
December 2005 to May 2007 requiring rede-
bridement or non urgent primary debridement,
were treated with either MDT or conventional
debridement. Each patient needing such
debridement was offered MDT as a form of
treatment. Antibiotics were given as indicated
by the presence of sepsis (spiking temperature,
raised total whites) or the presence of cellulitis.
Because of the limited supply of sterilemaggots,
only a maximum of two patients were on the
therapy at any one time. Both groups had foot
woundsgradedat theonset using theUniversity
of Texas Diabetic Foot Classification System.
Exclusion criteria
Patients with the following were excluded:
1. Gangrenous wounds
2. Necrotising fasciitis
3. Abscesses
4. Wounds with exposed viable bones
5. Wounds with exposed viable tendons
6. Wounds that are profusely bleeding
7. Ischaemic wounds [ankle-brachial systolic
index (ABSI) of less than 0
75 (moderate
ischaemia)]
8. Patients who have entomophobia
Patients selected for and agreeable to MDT
were asked to sign an informed consent form.
Thereafter, therapywas initiatedwithin the next
2 days. We required some time for our ento-
mology colleagues from IMR to prepare the
maggots.
Transport of maggots
Themaggotswere transported in a sterile vial in
a cooler box at 4
C. As the Institute for Medical
Research is located just next to the HKL,
maintaining the temperature during transport
was not a problem.
Wound dressing and treatment
For the study group, the maggots were applied
directly onto the wound with a sterile spatula.
Around ten maggots were needed for every
1 cm2 of wound surface. The wound was then
covered with light gauze and then the entire
wound was sealed with OpSite (Smith &
Nephew, Mull, UK). Some small fenestrations
were made in the OpSite dressing to allow
drainage of fluid. A gamgee was placed over this
to absorb the fluid. Then, the entire foot was
looselybandagedwith acrepebandage. Thecrepe
bandage and gamgee were changed as necessary
before the washout, that is if the dressing had
become soaked. A washout of the wound was
performed after 48 hours of application of mag-
gots. This was performed using normal saline.
Maggots were reapplied after that if needed. If no
change was noticed after three consecutive
applications then MDT was abandoned and
debridement was carried out as needed. All
patients were converted to subcutaneous insulin
during the duration of treatment.
For the control group, wound dressing was
performed daily with normal saline only and
the necessary surgical debridement and de-
sloughing was performed as indicated. All pa-
tients were converted to subcutaneous insulin
during the duration of treatment.
Outcome measurements
We devised our own wound outcome scoring
system, one for the MDT group and one for the
Key Points
 our study objective was to
compare MDT with L. cuprina
and conventional debridement
for the treatment of infected
diabetic foot ulcers
 our hypothesis is that MDT is as
effective as conventional
debridement in the treatment
of infected diabetic foot ulcers
MDT with Lucilia cuprina
40 ª 2009 The Authors. Journal Compilation ª 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc