Journal of Isfahan Medical School

Journal of Isfahan Medical School

Application of Fish Skin Dressings in the Treatment of Diabetic Foot Ulcers: A Comprehensive Review

Document Type : Review Article

Authors
Mansour Siavash 1
Tahereh Sadeghi 2
Mojtaba Akbari 3
1 Professor of Endocrinology, Isfahan Endocrine & Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 MSc, Isfahan Endocrine & Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 PhD in Epidemiology, Isfahan Endocrine & Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
10.48305/jims.v44.i858.0575
Abstract

Background: Diabetic foot ulcer is a common and serious complication of diabetes that can lead to disability and amputation, imposing a significant economic burden on healthcare systems. Despite standard treatments, many of these ulcers do not fully heal. Recently, fish skin dressing has emerged as a novel and effective approach for treating such wounds
Methods: Multiple clinical and research studies have investigated the effects of fish skin-based dressings on diabetic foot ulcers. These studies assessed the natural collagen structure, anti-inflammatory, antibacterial, antiviral properties, and biocompatibility of fish skin
Findings: Findings indicate that fish skin dressing accelerates wound healing and reduces side effects. Compared to conventional methods, this dressing is associated with higher healing rates, reduced pain, fewer dressing changes, and lower treatment costs. Additionally, the low risk of viral disease transmission and high compatibility with human tissue make fish skin dressings particularly safe and suitable in resource-limited settings.
Conclusion: Fish skin dressing provides a promising outlook for the management of chronic diabetic foot ulcers and other skin injuries. Despite its significant benefits, further research is needed to assess long-term safety and efficacy, as well as to improve processing and sterilization protocols

Highlights

Mansour Siavash: Google Scholar ,PubMed

Tahereh Sadeghi: Google Scholar

Mojtaba Akbari: Google Scholar ,PubMed

Keywords
Diabetic foot ulcer
Fish skin dressing
Wound healing
Fish skin grafts
Acellular fish skin
Subjects
1.     Hosseinkhani R, Feizi A, Mollabashi Z, Akbari M, Torbatian A, Siavash M. Evaluation of the Accuracy of the Glycated Hemoglobin (HbA1c) Index Measured by the Clover A1c Self Analyzer Device Compared to Standard Methods [in Persian]. J Isfahan Med Sch 2025; 42(795): 1112-20.
2.     Karbasiun F, Shahrokh S, Yazdi M, Siavash M, Tabatabaee A. Comparison of Procalcitonin Levels in Diabetic Foot Ulcer Infection and Osteomyelitis: A Systematic Review and Meta-Analysis. Int J Low Extrem Wounds 2026; 25(2): 414-26.
3.     Siavash M, Aghanouri Z. Recommendations for ramadan fasting in patients with diabetes mellitus based on integrative medicine and according to the persian culture-a review study [in Persian]. J Isfahan Med Sch 2023; 41(706): 42-53.
4.     Sivakumar DT, Murray B, Moore Z, Patton D, O'Connor T, Avsar P. Can thermography predict diabetic foot ulcer risk in patients with diabetes mellitus? A systematic review. J Tissue Viability 2024; 33(4): 530-41.
5.     Fan Z, Liu Y, Xie H, Yang Q, Zhang G, Zhang P, Ding H. Analysis of risk factors for foot ulcers in diabetes patients with neurovascular complications. BMC Public Health 2025; 25(1): 792.
6.     OuYang H, Yang J, Wan H, Huang J, Yin Y. Effects of different treatment measures on the efficacy of diabetic foot ulcers: A network meta-analysis. Front Endocrinol (Lausanne) 2024; 15: 1452192.
7.     Dhatariya K, Abbas ZG. Estimated costs of treating two standardised diabetes-related foot ulcers of different severity - A comparison of 7 global regions. Diabetes Res Clin Pract 2025; 221: 112036.
8.     Tahmasebi-Ghorrabi A, Saki Malehi A, Torabipour A, Hosseinipour A, Davodian M, Shahriari A. Cost-of-Illness Analysis of Diabetic Foot Ulcer: A Prevalence-Based Approach in Southwest of Iran. Med J Islam Repub Iran 2025; 39: 1.
9.     Lee SH, Kim SH, Kim KB, Kim HS, Lee YK. Factors Influencing Wound Healing in Diabetic Foot Patients. Medicina (Kaunas) 2024; 60(5): 723.
10.  Zhao Y, Shen Q-Q. Acellular fish skin grafts in diabetic foot ulcer care: Advances and clinical insights. World J Diabetes 2025; 16(1): 100597.
11.  American Diabetes Association Professional Practice Committee. 12. Retinopathy, neuropathy, and foot care: standards of care in diabetes—2025. Diabetes Care. 2025; 48(1 Suppl 1): S252-S265.
12.  Ibrahim M, Ayyoubi HS, Alkhairi LA, Tabbaa H, Elkins I, Narvel R. Fish skin grafts versus alternative wound dressings in wound care: a systematic review of the literature. Cureus 2023; 15(3): e36348.
13.  Dardari D, Potier L, Sultan A, Francois M, M’bemba J, Bouillet B, et al. Intact fish skin graft vs. standard of care in patients with neuroischaemic diabetic foot ulcers (kerefish study): an international, multicentre, double-blind, randomised, controlled trial study design and rationale. Medicina (Kaunas) 2022; 58(12): 1775.
14.  Salloum A, Bazzi N, Squires S, Chu T, Benedetto P, Benedetto A. Comparing the application of various engineered xenografts for skin defects: A systematic review. J Cosmet Dermatol 2023; 22(3): 921-31.
15.  Seth N, Chopra D, Lev-Tov H. Fish skin grafts with omega-3 for treatment of chronic wounds: exploring the role of omega-3 fatty acids in wound healing and a review of clinical healing outcomes. Surg Technol Int 2022; 40: 38-46.
16.  Verde MEQL, Ferreira-Júnior AEC, de Barros-Silva PG, de Castro Miguel E, Mathor MB, Lima-Júnior EM, et al. Nile tilapia skin (Oreochromis niloticus) for burn treatment: ultrastructural analysis and quantitative assessment of collagen. Acta Histochemica 2021; 123(6): 151762.
17.  Samiei MH, Jamili S, Nikukar H, Razban V. Isolation and Evaluation of Collagen from the Fish (Thunnus Tonggol) Skin: A Biological Material for Medical Tissue Engineering [in Persian]. J Shahid Sadoughi Univ Med Sci 2022; 30 (6) :4932-48.
18.  Esmaeili A, Rahimi A, Abbasi A, Hasannejad-Asl B, Bagheri-Mohammadi S, Farjami M, Keshel SH. Processing and post-processing of fish skin as a novel material in tissue engineering. Tissue Cell 2023; 85: 102238.
19.  Esmaeili A, Biazar E, Ebrahimi M, Heidari Keshel S, Kheilnezhad B, Saeedi Landi F. Acellular fish skin for wound healing. Int Wound J 2023; 20(7): 2924-41.
20.  Ibrahim A, Hassan D, Kelany N, Kotb S, Soliman M. Validation of three different sterilization methods of Tilapia skin dressing: Impact on microbiological enumeration and collagen content. Front Vet Sci 2020; 7: 597751.
21.  Elshahawy AM, Mahmoud GA-E, Mokhtar DM, Ibrahim A. The optimal concentration of silver nanoparticles in sterilizing fish skin grafts. Scientific Reports 2022; 12(1): 19483.
22.  Ibrahim A, Fahmy HM, Mahmoud GA-E, Soliman M, Elshahawy AM. New strategies for sterilization and preservation of fresh fish skin grafts. Sci Rep 2024; 14(1): 1253.
23.  Orrego CE, Salgado N, Sarmiento LF. Freeze drying and vacuum drying. Drying Technology in Food Processing 2023: 203-40.
24.  Júnior EML, de Moraes Filho MO, Costa BA, Alves APNN, de Moraes MEA, do Nascimento Uchôa AM, et al. Lyophilised tilapia skin as a xenograft for superficial partial thickness burns: a novel preparation and storage technique. J Wound Care 2020; 29(10): 598-602.
25.  Dias MTPM, Bilhar APM, Rios LC, Costa BA, Júnior EML, Alves APNN, et al. Neovaginoplasty using Nile tilapia fish skin as a new biologic graft in patients with Mayer-Rokitansky-Küster-Hauser syndrome. J Minim Invasive Gynecol 2020; 27(4): 966-72.
26.  Fiakos G, Kuang Z, Lo E. Improved skin regeneration with acellular fish skin grafts. Engineered Regeneration 2020; 1: 95-101.
27.  Cadri S, Elrosasy A, Al Mawla AM, Albakri K, Abdelwahab OA, Soliman A, et al. The efficacy of Nile tilapia skin xenograft for treating superficial partial-thickness burn versus the standard of care: a meta-analysis of published trials. Arch Dermatol Res 2023; 316(1): 33.
28.  Kashwani R, Soman M, Mohite V, Rawat A. Tilapia fish skin in medicine: a comprehensive review of its therapeutic potential. Community Practitioner. 2024; 21(2): 234.
29.  Luze H, Nischwitz SP, Smolle C, Zrim R, Kamolz L-P. The use of acellular fish skin grafts in burn wound management—a systematic review. Medicina (Kaunas) 2022; 58(7): 912.
30.  Karhana S, Khan MA. Omega-3 Acellular Fish Skin Grafts for Chronic and Complicated Wounds: A Systematic Review of Efficacy and Safety. Dermatol Pract Concept 2025; 15(2): 4945.
31.  Ghosh B, Sánchez-Velazco DF, Prem P, Ali ASM, Dominique O, Shah SA, et al. Use of Nile tilapia fish skin in treatment for burn victims. International Journal of Surgery: Global Health 2023; 6(5): e0257.
32.  Zimba BL, Rwiza MJ, Sauli E. Utilizing tilapia fish skin biomaterial for burn wound dressing: A systematic review. Scientific African 2024; 24: e02245.
33.  Pignet A-L, Hecker A, Voljc T, Carnieletto M, Watzinger N, Kamolz L-P. The use of acellular fish skin grafts in burns and complex trauma wounds: a systematic review of clinical data. Plast Aesthet Res 2024; 11:40.
34.  Zhao C, Feng M, Gluchman M, Ma X, Li J, Wang H. Acellular fish skin grafts in the treatment of diabetic wounds: Advantages and clinical translation. J Diabetes 2024; 16(5): e13554.
35.  Tan APP, Chng JK. Fish skin acellular dermal matrix combined with negative pressure wound therapy for diabetic foot ulcers. Cureus 2025; 17(3): e80488.
36.  Lima-Verde MEQ, Parthiban SP, Junior AECF, de Barros Silva PG, Junior EML, de Moraes MO, et al. Nile tilapia fish skin, scales, and spine as naturally derived biomaterials for tissue regeneration. Curr Oral Health Rep 2020; 7(4): 335-43.
37.  Wang D, Maliakkal J, Sadat O, Codrea V, Nguyen J. Acellular fish skin grafts for treatment of periocular skin defects. Ophthalmic Plast Reconstr Surg 2024; 40(6): 681-4.
38.  Hashempour R, MirHashemi S, Mollajafari F, Damiri S, ArabAhmadi A, Raei B. Economic burden of diabetic foot ulcer: a case of Iran. BMC Health Serv Res 2024; 24(1): 363.
39.  Najafpour Z, Rashidi T, Seyedtabib M, Yazdanpanah L. Comparison of costs related to health services in two groups of patients with diabetic foot ulcer and patients without this complication: a matched cohort study. J Diabetes Metab Disord 2025; 24(1): 127.
40.  Dardari D, Potier L, Sultan A, Francois M, M'Bemba J, Bouillet B, et al. Intact fish skin graft for deep diabetic foot ulcers: results from the KEREFISH randomized controlled trial. Diabetes Metab 2025; 51(6): 101691.
41.  Michael S, Winters C, Khan M. Acellular Fish Skin Graft Use for Diabetic Lower Extremity Wound Healing: A Retrospective Study of 58 Ulcerations and a Literature Review. Wounds 2019; 31(10): 262-8.
42.  Ruiz-Munoz M, Martinez-Barrios F-J, Cervera-Garvi P, Lopezosa-Reca E, Marchena-Rodriguez AJ. Fish skin grafts versus standard of care on wound healing of chronic diabetic foot ulcers: A systematic review and meta-analysis. Prim Care Diabetes 2024; 18(3): 291-8.
43.  Zou Y, Mao Z, Zhao C, Fan Z, Yang H, Xia A, Zhang X. Fish skin dressing for wound regeneration: A bioactive component review of omega-3 PUFAs, collagen and ECM. Int J Biol Macromol 2024; 283: 137831.
44.  Mukherjee S, Bhattacherjee S, Keswani K, Nath P, Paul S. Application of Tilapia fish skin in treatment of burn patients. Biocatalysis and Agricultural Biotechnology 2024; 59: 103254.
45.  Adhikari SP, Paudel A, Sharma A, Thapa B, Khanal N, Shastri N, et al. Development of decellularized fish skin scaffold decorated with biosynthesized silver nanoparticles for accelerated burn wound healing. Int J Biomater 2023; 2023(1): 8541621.
46.  Meganathan G, Balasubramanian B, Meyyazhagan A, Paul J, Chaudhary A, Pappuswamy M. Review on the fish collagen-based scaffolds in wound healing and tissue engineering. Natur al Resources for Human Health 2024; 4: 1–23.
47.  Dardari D, Piaggesi A, Potier L, Sultan A, Diener H, Francois M, et al. Intact fish skin graft to treat deep diabetic foot ulcers. NEJM Evid 2024; 3(12): EVIDoa2400171.
48.  Das S, Baker AB. Biomaterials and nanotherapeutics for enhancing skin wound healing. Front Bioeng Biotechnol 2016; 4: 82.
49.  Pourjabbar B, Biazar E, Heidari Keshel S, Baradaran‐Rafii A. Improving the properties of fish skin collagen/silk fibroin dressing by chemical treatment for corneal wound healing. Int Wound J 2023; 20(2): 484-98.
50.  Afshar M, Rezaei A, Eghbali S, Nasirizadeh S, Alemzadeh E, Alemzadeh E, et al. Nanomaterial strategies in wound healing: A comprehensive review of nanoparticles, nanofibres and nanosheets. Int Wound J 2024; 21(7): e14953.
51.  Lullove EJ, Liden B, Winters C, McEneaney P, Raphael A, Lantis Ii J. A Multicenter, Blinded, Randomized Controlled Clinical Trial Evaluating the Effect of Omega-3-Rich Fish Skin in the Treatment of Chronic, Nonresponsive Diabetic Foot Ulcers. Wounds 2021; 33(7): 169-77.
52.  Jugnet AC, Benard T, Lequint C, Bobony E, Pieheiro A-R, Winther T, et al. Intact fish skin graft a new hope for the treatment of diabetic foot ulcers: A case report. World J Diabetes 2024; 15(12): 2353.
53.  Chang P, Guo K, Li S, Wang H, Tang M. In situ sodium chloride cross‐linked fish skin collagen scaffolds for functional hemostasis materials. Small 2024; 20(11): 2208001.
54.  Biazar E, Heidari Keshel S, Rezaei Tavirani M, Kamalvand M. Healing effect of acellular fish skin with plasma rich in growth factor on full‐thickness skin defects. Int Wound J 2022; 19(8): 2154-62.
Ibrahim A, Soliman M, Kotb S, Ali MM. Evaluation of fish skin as a biological dressing for metacarpal wounds in donkeys. BMC Vet Res 2020; 16(1): 472.
Journal of Isfahan Medical School
Volume 44, Issue 858
2nd Week, June
May and June 2026
Pages 575-584

  • Receive Date 22 July 2025
  • Accept Date 27 June 2026