Larval debridement therapy for diabetes-related foot ulcers: Evidence, mechanisms and practical guidance

Larval debridement therapy (maggot therapy) uses sterile Lucilia spp larvae to remove necrotic tissue, reduce bacterial burden and may support healing. The 2023 International Working Group on the Diabetic Foot wound-healing guideline could not recommend biosurgical debridement because it found no randomised controlled trials meeting its prespecified criteria. We searched PubMed, the Cochrane Library, Scopus and Google Scholar (inception-June 2025) for clinical studies of larval therapy in diabetes-related foot ulcers. Evidence is limited: one randomised trial (n = 50) reported reductions in Staphylococcus aureus and Pseudomonas aeruginosa colonisation after 48-96 h when larval therapy was added to standard care; another randomised trial (n = 54) found faster debridement with free-range larvae than with bagged larvae. Observational studies suggest rapid debridement and possible reductions in bioburden, but healing outcomes are inconsistent and at high risk of bias. Larval therapy may be considered as an adjunct for sloughy/necrotic ulcers when conventional debridement is unsuitable, alongside multidisciplinary care. Larger trials are needed.