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Body Piercing: More Than Skin Deep

L. Hogan MSN, RN, FNP-BC1 and M. L. Armstrong EdD, RN, FAAN2
1. Texas Tech University Health Sciences Center, Anita Thigpen Perry School of Nursing, Lubbock, TX, USA
2. Texas Tech University Health Sciences Center at Highland Lakes, Marble Falls, TX, USA

ABSTRACT

Young adult populations (18-25 years of age) throughout the world have latched onto the mainstream trend of body piercing. Best health care practices for these individuals involves the knowledge of proper procedural techniques, postsite care, common complications, and treatment modalities.

Key Words: blood transfusions, body art, body piercings, infective endocarditis, piercing infections, scarring, skin trauma

Creativity and ubiquity are the only constants of body piercing.1,2 Yet, no matter what one’s opinion is about body piercings, don’t become distracted by them and delay important medical care.3 Body piercing has been around for centuries in various societies as part of ritualistic or cultural practices, and now it is rapidly becoming a worldwide mainstream fashion trend, especially among young adults aged 18-25 years. According to Armstrong et al., body piercing is defined as the insertion of a needle to create a fistula-like opening (into either cartilage or skin) for the introduction of decorative ornaments, which can include insertion of jewelry, plastic or wood plugs, beads, or pearls.1 Current US body piercing rates are approximately 36%,5 and those figures are similar for smaller studies2,6 that also excluded ear lobe piercings. Women tend to report obtaining body piercings more so than men do.

Body Piercing Regulated Environment

An actual body piercing procedure only takes a few moments, but given the invasive technique of the procedure, an earlier study6 cited frequent infections (45%) and skin irritations (39%) as prevalent piercing site problems, often because no aftercare instructions for proper skin treatment were provided. Now, considering the overall amount of body piercing worldwide and the presence of a better (but certainly not perfect) regulated body art environment,7 the number of self-reported complications remain around 17%-35%.8 While most body piercings are not problematic, the potential for localized infections, as well as associated systemic diseases, is present so long as the piercing site remains open.1,9,10 These infections may become an even more invasive problem with the emergence of community acquired methicillin resistant Stapthylococcus aureus (CA-MRSA).3

Blood transfusions have also been affected by the increase in body piercing.11 For many years, individuals with new piercings could not donate blood for at least 1 year following the piercing. In 2005, the Canadian Blood Services reduced their deferral period from 12 to 6 months, and the US has reduced their deferral period (which varies from state to state) if body art was obtained in regulated areas. Current evidence indicates disease transmission has not increased with these new regulations, and Spain is currently examining a deferral period reduction to 4 months.

Pierced Seeking Prompt Treatment

Many individuals with body piercings do not perceive their body art as “permanent”; frequently they say, “If I don’t like it, I can remove it.” They are often aware of the procedural risks; however, when initial site irritation, pain, or oozing occurs, most skin problems may be dismissed or self-treated.12 Other times, individuals are “embarrassed,” thinking the infection could be their fault, and/or “fear” that the jewelry needs to be removed. Additionally, findings from recent studies13-15 suggest that these individuals look to the internet or return to the piercer for assistance, instead of seeing their health care provider, due to the clinicians’ lack of adequate knowledge, judgmental perspectives about body art, and limited educational resources about piercings.

Piercing History Helps Determine Your Diagnosis

Where was the piercing obtained?

Stores/kiosks in shopping malls provide ear lobe and high rim ear piercings using piercing guns, and sell benzalkonium chloride solution as their after-care product of choice. This solution does not have adequate microbicidal activity against Pseudomonas aeruginosa infections and has been frequently mentioned in outbreaks of auricular chondritis.16-19 Additionally, limited employee training and supervision, along with inadequate quality control measures have also been reported.

What type of after-care was done?

Diminished skin integrity is greater with newly acquired body piercings, especially from procedures obtained during warm weather months.12 In a regulated body art environment, piercing artists emphasize conscientious care of the piercing site following the procedure with careful monitoring of the site until it is completely healed.7,10,20-21 While healing times are dependent on site location, facial piercings usually heal within 2 months, and covered areas can take up to 6 months. Yet, a completely healed site requires judicious care of the piercing site for at least 1 year until the skin epithelializes, “toughening up” the area for the adjustment of wearing various piercing inserts.1

What kind of jewelry was placed in the site?

Due to the overall increase in jewelry containing nickel, there has been a marked increase in contact dermatitis related to nickel allergy,22 especially if it is purchased in shopping malls. Carefully selecting piercing jewelry (comprised of niobium, titanium, 300 grade surgical steel, or gold) that is found in piercing studios helps avoid allergen exposure, scarring, and risks of delayed infection.9,21

Should jewelry be removed or not?

Retaining the jewelry at the site when an infection initially occurs, allows for better drainage and epidermal healing, whereas removal can potentiate abscess formation in deeper skin structures. However, if there is not resolution within 5-7 days, the jewelry should be removed, followed by surgical incision and drainage, and possible hospitalization with intravenous antibiotic therapy, especially for high ear-rim piercing infections.16-19

Local Complications

Secondary trauma from body piercings (Table 1)12 can occur frequently at the naval (40%), ear (35%), nose (12%), tongue, chin, eyebrows, genitals (8%), and nipple (5%). Common complications include bleeding, bacterial or viral infections, mechanical tissue tearing, keloid scarring, nerve impairment, and allergies. These complications can arise from the body piercing procurement and/or limited procedural after-care. Embedded earrings are also frequently seen.23 Exposed wounds from piercing inserts can also occur from physical assaults, motor vehicle accidents, or aggressive contact sports.12 Additionally, as more people retain their body art for longer periods of time, other effects can evolve, which may involve further invasive, corrective procedures from a specialist.

Management of Infections

Bacterial skin infections at or near the site are considered the most commonly reported complication of body piercings, with causative organisms primarily consisting of 2 gram-positive bacteria: Staphylococcus, and group A Beta-hemolytic Streptococcus, and 1 gram-negative bacteria: Pseudomonas.24 Ideally, pharmacological interventions would be pathogen-specific, based on cultures of the affected site. However, due to the length of time cultures take to be processed, it is not always reasonable to delay treatment, as a more severe infection can ensue if left untreated.

Current infectious disease guidelines24 recommend that the majority of minor skin and soft-tissue infections may be treated with penicillins, first-generation or second-generation oral cephalosporins, macrolides, or clindamycin. Of note, though, is that there is growing resistance of MRSA strains to clindamycin, in the range of approximately 50%. CA-MRSA strains showed continued responsiveness to trimethoprim-sulfamethoxazole and tetracycline. Ideally, after initiation of antibiotic therapy, patient follow-up at 24-48 hours is important. If the patient is not demonstrating a positive response to therapy, the clinician should strongly consider that the progression of infection may be a result of resistance or a sign of a more severe infection.24 In the event that the infection causes the formation of skin abscesses, the clinician should consider a more aggressive combination approach to therapy, including antibiotics and possible incision and drainage of related skin abscesses.11

Systemic Infections from Piercing

Although rare, systemic infections, such as infective endocarditis (IE) or sepsis, can also occur.25 These are thought to be “triggered either by normal flora at the puncture site, microorganism colonization around the jewelry, or by a localized site infection that stimulates episodes of transient bacteremia, that can seed various areas of the heart.”25 More than 25 IE cases in the past decade have come from tongue, navel, earlobe, lower lip, and nipple piercings. If an individual with a new piercing (i.e., up to 4 months), with or without a history of congenital heart disease, presents with unexplained fever, night chills, weakness, myalgia, arthralgia, lethargy, or malaise, IE should be considered, especially as body piercing continues to increase. Prophylactic antibiotic regimens have been suggested since 1999, but the treatment is still being debated.24

Conclusion

While piercers are knowledgeable regarding the techniques and procedures of body piercing, treatment for health concerns and complications related to piercings should be provided by knowledgeable clinicians. Non-judgmental, informative care is crucial when complications arise.1,20 Yet, as you work with those who have piercing complications, remember that removing a piercing does not remove the individual’s motive or rationale for obtaining the piercing. Often, within about 6 months they will obtain another,1,2,20 so applicable education about piercing care remains vital for preventing further or repeated sequelae.

Recommendations for care of a new piercing as defined by the Association of Professional Piercers include:22

  • Instruct patients to wash the piercing site with soap and water or a diluted saline solution (1/8 tsp of salt to 8 oz of water) twice per day, because piercing tracts can become portals or reservoirs for viruses and bacteria.
  • Recommend the use of antiseptic mouthwash (alcohol-free) for oral piercings.
  • Instruct individuals with oral piercings to use ice chips or other cool fluids to reduce swelling and ease discomfort during the initial healing phase.
  • Advise against the use of alcohol, Hibiclens® (Mölnlyke Healthcare), hydrogen peroxide, Bactine® (Bayer Healthcare), and Betadine® (Purdue Products LP) in piercing care.
  • Encourage patients to search the Association of Professional Piercers website21 for further educational material regarding each type of piercing.

Body Piercing Site Documented Complications
Cheek, tongue, uvula, lips
  • Post-piercing edema may cause airway obstruction.
  • Other problems include altered eating habits, salivary gland injuries, increased salivary flow, speech impediments (lisp), pain, loss of taste, permanent numbness, and uncontrolled drooling.
  • Dental trauma of the teeth includes dental abrasions, cusp fractures, chips, and cracks, called “wrecking ball” fractures, and the “cracked-tooth syndrome.”
  • Swallowing or aspirating loosened jewelry can compromise the airway and cause gastrointestinal damage.
  • Lingual blood vessel perforation (during piercing) can cause severe bleeding, hematomas, or hypovolemic shock.
  • Pierced athletes have the greater risk for infection because of contact trauma, dirty activity settings, increased blood flow, increased perspiration, and increased breathing rates.
  • Labret piercing jewelry (cleft of chin) can become embedded in the lower lip soft tissue.
Ear
  • Ear lobe (not considered a true body piercing)
  • Tears or splits from pulling on the earrings or stretching the skin of the ear lobe, perhaps never returning to it original form if wearing heavy jewelry or flesh tunnels.
  • Mid- to high-rim cartilage
  • Auricular perichondritis, perichondrial abscess, or auricular necrosis can occur with or without symptoms.
  • A subperiosteal abscess with perichondritis causes loss of cartilage.
  • Severe ear deformities can be seen with transcartilagenous piercings, sometimes called “cauliflower ear.”
  • Additional complications include keloid formation, allergic metal contact dermatitis, and embedded jewelry.
Eyebrows
  • Local inflammation can result, producing eyelid redness, pressure, pain, swelling of the face and cheek, and a solid, tender, movable, cherry-size swelling of the eyebrow.
Genitals 12-15

Women: labia minora, labia majora, and the clitoral prepuce or body

Men: foreskin, scrotum, urethra, perineum, and penile glans. Creativity abounds with this site.*
Women:
  • Many unsubstantiated complications such as scarring, allergic metal reactions, bleeding, keloids, and infections of genital piercings have been reported, yet current medical literature and research is limited. The major self-reported complications are site sensitivity and skin irritation.15 Questions remain if piercings should be removed for delivery.
Men:
  • Prince Albert (most common male genital piercing that perforates the urinary meatus and corona) frequently alters urinary flow.
  • Other single case reports discuss: urethral rupture and tissue destruction, large-vessel or nerve injury and infection causing infertility from an ascending infection, such as prostatitis or testis infection due to scrotal piercing, and penile rings causing engorgement and priapism.
Navel
  • Infection rates increase because of increased skin moisture from friction and tight-fitting clothes.
  • Superficially placed piercings cause scarring by migrating to the skin surface, especially with obesity and during the third trimester of pregnancy.
Nipple

(done to enlarge the nipple, for esthetics, and to enhance sensitivity)14,16
  • It has been reported that breastfeeding with nipple piercing can cause breast discomfort for the mother or, if the jewelry is dislodged, could cause the infant to aspirate the jewelry, yet the international breastfeeding organization, La Leche League, supports breastfeeding with healed nipple piercings; individual patient assessment is emphasized to provide the best care and to decide whether or not the jewelry should be removed. For further information, see: http://www.lalecheleague.org/llleaderweb/LV/LVJunJul99p64.html.)
  • One report of mastitis due to Mycobacterium abscessus and another of hyperprolactinemia and galactorrhea have been cited.
  • Dislodgement from physical assaults and aggressive contact sports can occur.
Nose
  • Cartilage piercings may cause septal hematomas.
  • Nasal piercings can cause edema and extra mucous formation.
  • Later, the nasal stud can become embedded in the edematous nasal tissue.
  • Granulomatous perichondritis may occur due to alar cartilage that is destroyed by granulomatous inflammation.
  • Nasal studs may be aspirated or swallowed; a nasal ring may be pulled out due to the jewelry migrating forward.
  • Piercing across the bridge of the nose is risky because of the many fascicles present.

Table 1: Secondary trauma occurring at specific body piercing sites12

*Usually heavy-gauge jewelry is worn, but beads, pearls, or other inert material can be inserted under penile tissue and is called penis marbles, nodules, or bulleetus.

Table and Listing of Early Piercing Care are reprinted with permission. Kuchinski A, Pereira P, Armstrong ML. Caring for Pierced Patients: Attitudes, Secondary Trauma, and Forensic Evidence. Mosby’s Nursing Consult at: http://www.nursingconsult.com/das/stat/view/138582404-2/cup. Published September 16, 2008. Accessed May 20, 2009.



References

  1. Armstrong ML, Koch JR, Saunders JC, et al. The hole picture: risks, decision making, purpose, regulations, and the future of body piercing. Clin Dermatol 25(4):398-406 (2007 Jul-Aug).
  2. Armstrong ML, Roberts AE, Owen DC, et al. Toward building a composite of college student influences with body art. Issues Compr Pediatr Nurs 27(4):277-95 (2004 Oct-Dec).
  3. Centers for Disease Control and Prevention. National MRSA Education Initiative: Preventing MRSA skin infections. At: www.cdc.gov/mrsa/mrsa_initiative/skin_infection/index.html. Accessed Aug 2009.
  4. DeBoer S, Amundson T, Angel E. Managing body jewelry in emergency situations: misconceptions, patient care, and removal techniques. J Emerg Nurs 32(2):159-64 (2006 Apr).
  5. Pew Research Center For the People & the Press: How young people view their lives, futures and politics: A portrait of Generation Next (2007). At: www.people=press.org. Accessed May 2008.
  6. Greif J, Hewitt W, Armstrong ML. Tattooing and body piercing: body art practices among college students. Clin Nurs Research 8(4):238-44 (1999 Nov).
  7. Armstrong ML. Tattooing, body piercing, and permanent cosmetics: A historical and current view of state regulations, with continuing concerns. J Enviro Health 67(8):38-43. (2005 Apr).
  8. Mayers L, Chiffriller S. Sequential survey of body piercing and tattooing prevalence and medical complication incidence among college students. Arch Pediatr Adolesc Med 161(12):1219-20 (2007 Dec).
  9. Beers MS, Meires J, Loriz L. Body piercing: coming to a patient near you. Nurse Pract 32(2):55-60 (2007 Feb).
  10. Meltzer DI. Complications of body piercing. Am Fam Physician 72(10):2029-34 (2005 Nov).
  11. Goldman M, Xi G, Yi QL, et al. Reassessment of deferrals for tattooing and piercing. Transfusion 49(4):648-54 (2009 Apr).
  12. Kuchinski A, Pereira P, Armstrong ML. Caring for Pierced Patients: Attitudes, Secondary Trauma, and Forensic Evidence. Mosby's Nursing Consult. At: http://www.nursingconsult.com/das/stat/view/138582404-2/cup. Accessed May 2009.
  13. Caliendo C, Armstrong ML, Roberts AE. Self-reported characteristics of women and men with intimate body piercings. J Adv Nurs 49(5):474-84 (2005 Mar).
  14. Young C, Armstrong ML. What nurses need to know when caring for women with genital piercings. Nurs Womens Health 12(2):129-38 (2008 Apr).
  15. Young C, Armstrong ML, Roberts AE, et al. A triad of evidence for care of women with genital piercings. J Am Acad Nurs Pract (in press).
  16. Widick MH, Coleman J. Perichondrial abscess resulting from a high ear-piercing--case report. Otolaryngol Head Neck Surg 107(6 Pt 1):803-4 (1992 Dec).
  17. Hanif J, Frosh A, Marnane C, et al. Lesson of the week: "High" ear piercing and the rising incidence of perichondritis of the pinna. BMJ 322(7291):906-7 (2001 Apr).
  18. Keene WE, Markum AC, Samadpour M. Outbreak of Pseudomonas aeruginosa infections caused by commercial piercing of upper ear cartilage. JAMA 291(8):981-5 (2004 Feb).
  19. More DR, Seidel JS, Bryan PA. Ear-piercing techniques as a cause of auricular chondritis. Pediatr Emerg Care 15(3):189-92 (1999 Jun).
  20. Stirn A. Body piercing: medical consequences and psychological motivations. Lancet 361(9376):1205-15 (2003 Apr).
  21. The Association of Professional Piercers. Suggested aftercare of body piercings. At: www.safepiercing.org. Accessed May 2009.
  22. Copeland SD, DeBey S, Hutchison D. Nickel allergies: implications for practice. Dermatol Nurs 19(3):267-8, 288 (2007 Jun).
  23. Timm N, Iyer S. Embedded earrings in children. Pediatr Emerg Care 24(1):31 (2008 Jan).
  24. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 41(10):1373-406 (2005 Nov).
  25. Armstrong ML, DeBoer S, Cetta F. Infective endocarditis after body art: a review of the literature and concerns. J Adolesc Health 43(3):217-25 (2008 Sep).
  26. The American Red Cross. (2009). Donor Eligibility. At: www.redcross.org/en/eligibility. Updated August 31, 2009.

In this issue:

  1. Management of Hirsutism
  2. Body Piercing: More Than Skin Deep
  3. Update on Drugs and Drug News - September 2009