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Infectious Complications of Body Piercing
S. Samantha M. Tweeten and Leland S. Rickman
From the University of California, San Diego (UCSD)/San Diego State University Joint Doctoral Program in Public Health (Epidemiology) and the Division of Infectious Disease, Department of Medicine, UCSD School of Medicine, San Diego, California Body piercing appears to be gaining in popularity and social acceptance. With the increase in
the number of piercings, it is likely that health care providers may see an increase in the complica-
tions resulting from these piercings. These may include the transmission of hepatitis viruses and
bacteria at the time of the piercing or in the course of wound care. We review the infectious
complications that have resulted from body piercing and have been documented in the medical
literature.
Body piercing, the use of needles, rings, steel posts, or other a penile piercing, subsequently named for him (and purported adornments that penetrate the skin and other structures of the to be a common practice among the well-dressed men of human body, predates history. Piercing appears to be increasing London at the time). Its purpose was said to be to hold the in popularity and, as discussed in a prior review of the infec- penis tightly against the thigh so that the stylish tight trousers tious complications of tattooing [1], may increase the risk of would fit better [5]. In Europe and North America, body various complications. The medical literature on postpiercing piercing has been seen by those in ‘‘punk’’ and antiestablish- infections occurring in areas other than the ear is limited, and ment subcultures as symbolic of deviance and rebellion, par- there are few reliable data on incidence or prevalence. Most ticularly when tattooing was discarded as being too main- publications are case reports. It is probable, however, that prac- titioners will see an increase in infections in a variety of pierced Apparently gaining in popularity, body piercing also appears body sites. We review the infectious complications of body to be gaining limited social acceptance. The ear is still the piercing that have been documented in the medical literature, most common body piercing site. However, other facial sites, in an effort to increase clinicians’ awareness of potential prob- including the eyebrow, lip, nose, and tongue, as well as the hidden sites of nipples, navel, and genital areas of both sexes,are being pierced with increasing frequency [7]. Owing in partto the more intimate nature of some piercings, there are no See article on related topic on pages 767 – 8.
reliable statistics or demographic data available about the peo-ple being pierced. One survey indicates that £80% of Ameri-can women have pierced ears [8]. Infections seen in ear sites Background and Demographics of Body Piercing
may thus reflect potential infectious complications associatedwith other piercing sites.
Until recently in this century, body piercing at sites other People pierce their bodies for a variety of reasons. The than the earlobe has been relatively rare in western culture.
counterculture youth are thought to be more inclined toward However, there is a long history of body decoration by piercing facial piercings that may provide increased shock value as the skin. Such piercings have been done as a rite of passage they are seen by others [5]. Although genital piercings have or to indicate marriageability or social standing [2]. Roman anecdotally been seen primarily in homosexual men, hetero- centurions were said to have pierced their nipples to hold their sexuals (both male and female) are getting pierced in increas- capes and as a sign of loyalty to the Emperor [3]. Mayans ing numbers for both sexual and aesthetic reasons [9]. Sado- pierced their tongues for spiritual purposes [3]. The Pharaohs masochism has also been implicated in the recent increase of Egypt ceremoniously had their navels pierced [4].
in interest in body piercing [10], but many more people are Genital piercings were, and still are, seen in areas around being pierced for other reasons [11]. It may be done to in- the Indian Ocean and among peoples of the South Pacific [3, crease self-esteem. Young women in particular may be 4]. Prince Albert, consort to Queen Victoria, was said to have pierced at times when they feel they have lost control of theirlives [11].
Body piercing is perceived by some as a form of deviant Received 9 June 1997; revised 5 November 1997.
behavior that may lead to other risks. Fiumara and Eisen [12] Reprints or correspondence: Dr. Leland S. Rickman, UCSD Medical Center – stated that those with ‘‘exotic’’ piercings, primarily genital, 8951, 200 West Arbor Drive, San Diego, California 92103-8951.
were at high risk for sexually transmitted diseases. Their pa- Clinical Infectious Diseases
1998; 26:735 – 40
tients with these genital piercings appeared to be primarily ᭧ 1998 by The University of Chicago. All rights reserved.
1058–4838/98/2603 – 0028$03.00 homosexual men. Analysis of a sample of 20 high-school stu- dents who had been pierced at a variety of sites including The jewelry is selected with the type of piercing in mind.
the tongue and navel, however, found that the students were The type of piercing, location on the body, and client needs generally academically solid and had good attendance [13].
determine the gauge of the jewelry and the diameter of the People of all ages and professions are appearing in piercing rings or length of the ‘‘barbell’’ to be placed. Once the jewelry studios, requesting jewelry placement at all sites.
is chosen, a single-use, nonreusable setup should be used toperform the piercing. Any items that are not disposable mustbe autoclaved between clients, as should the jewelry to be Body Piercing Methods
placed. Single-use items such as needles and corks must be Regardless of the site of a piercing, aseptic techniques should packaged in individual sterile packaging. A piercer should wear always be used to reduce the risk of infection. Aftercare, the examination gloves, changing them between clients or anytime care of the piercing site after introduction of jewelry, is also contamination may have occurred [20].
of importance in preventing infection and must be meticulously Once the client is ready and has been placed on a flat surface, performed. Antibiotic prophylaxis, however, is not generally the piercer should cleanse the area to be pierced with a topical required for the prevention of bacterial endocarditis [14].
antiseptic. The site is marked to provide a guide for the needle The most common piercing site is the earlobe. This is often and is grasped with a Pennington forceps. A large-gauge (12 – pierced with a spring-loaded ‘‘gun,’’ which punctures the lobe 16-gauge) hollow needle is inserted quickly, and a cork is with a sharp metal stud. This effectively tears a hole through placed on the sharp end. The jewelry is brought through the the tissue. A backing is placed on the earring stud to hold it hole, following the needle in a needle-and-thread fashion, and in place. Recently, the piercing guns themselves have been is sealed with a bead, metal ball, or disk [4].
recognized as a possible vehicle for the transmission of viral The client is instructed not to touch the piercing until it is hepatitis. The guns are not easily cleaned and are infrequently healed, is taught how to cleanse daily, and is made aware of sterilized. The transmission of hepatitis B virus (HBV) has also the signs of infection and the chances of injury. Variations on been associated with spring-loaded finger-stick devices, which these procedures may occur. In piercing of the tongue, a longer have a similar mechanism of action to the piercing gun and ‘‘barbell’’ is usually initially placed to allow for edema of the may be inappropriately cleaned [13, 15].
tongue [4]. It is then replaced, if desired, with a shorter rod.
The gun method is used frequently by physicians as well as The client is instructed to use an antiseptic mouthwash several at department and jewelry stores. Ear piercing is also often done by friends or relatives with various household needles, Generally, local anesthesia is not used for body piercing. In sometimes with thread in the hole, or with jewelry. The piercing the Prince Albert penile piercing, the needle goes through the gun is designed for piercing earlobes only, as it is not adjustable urethra. A topical anesthetic may be applied and a needle- to deal with varying thicknesses of other tissues, and em- receiving tube used to guide the needle and to minimize tissue bedment of the earring backs is more likely to occur if the gun damage because of the increased potential for pain during the Body piercing is not always performed with an aseptic tech- Piercings done with an ear-piercing gun also require site nique. Some people choose to pierce themselves. This is rarely preparation. Generally, a topical antiseptic is applied to the functional, as the piercing must be done at sufficient depth to earlobe and the position of the piercing is marked on the lobe.
keep the jewelry in place. Too-shallow insertion may lead to A metal piercing stud with a sharpened end is placed in the rejection of the jewelry or an increased chance of injury. The gun and applied to the lobe, and the spring trigger is released choice of jewelry is also important. Surgical steel (300-grade), to drive the stud through the lobe, tearing through the tissue niobium, or gold is usually used, although contact dermatitis rather than creating a hollow tube through which the ring is may occur with surgical steel or gold [4]. Use of jewelry con- placed. The earring must be sterile and the piercing gun appro- taining other metals may lead to dermatitis or metal sensitiza- priately cleaned and sterilized to avoid infection. Aftercare is as important in ear piercing as it is in other piercings.
The jewelry most commonly inserted at piercing sites other Healing times for piercing vary according to placement.
than the ear consists of a barbell-shaped ornament, bent or Those areas that are exposed — ears, lips, eyebrows, and straight; a ring with a bead; a stud with a metal ball at one tongue — tend to heal quickly; the tongue heals in 3 – 6 weeks end and a flat disk on the other for the labret (a piercing through and the others in 6 – 8 weeks. Nipple piercing is more variable the area below the lower lip); or in the case of some septum and is said to be dependent on the type of clothing worn.
piercings, a tusk [4]. Inert plastics may also be placed after Such healing can take 8 – 16 weeks [4]. The wearing of tighter clothing is generally reported to inhibit healing. Navel piercings A reputable piercer should follow a protocol for all piercings may take up to 9 months to heal, reportedly in part because and adhere to safety guidelines [18]. The protocol follows asep- they are frequently covered by tight clothing such as jeans and tic surgical technique [19]. It begins with thorough instruction pantyhose [4]. Genital piercings are reported to take less time of the client about the procedure, risk, consent, and aftercare.
Infectious Complications of Body Piercing Complications of Piercing
S. aureus after their ear piercings became red and inflamed.
The first, a 15-year-old girl, and the second, a 14-year-old girl, Noninfectious Complications
experienced redness and swelling of the earlobe, and eventually Many noninfectious complications of piercing have been the diagnosis of hematogenous osteomyelitis of the iliac crest reported. In ear piercing, metal-allergic dermatitis may result was established. The third patient was a 2-week-old girl whose [21 – 25]. Use of the ear-piercing gun can result in earrings ears were pierced 2 days prior to admission to the hospital for being deeply embedded in the lobe [16, 26, 27], which may fever. Her blood and CSF cultures subsequently yielded be mistaken for keloids [28, 29]. Inflammation may become so extreme as to envelop the piercing jewelry [30]. Keloid S. aureus was also isolated from the external ear discharge formation may occur as a late complication of body piercing of a 5 1/2-week-old girl shortly after her ears were pierced [52].
[31 – 36]. Pseudolymphoma or lymphadenopathy may also oc- She was admitted to the hospital because of abdominal disten- cur with any piercing [37, 38], and sarcoidal tissue reaction tion and loose stools. McCarthy and Peoples [53] described a 6-year-old child with chronic neutropenia who developed toxic Torn ear lobes and other trauma are not uncommon among shock syndrome shortly after having her ears pierced. The those with pierced ears [32, 40, 41], but injuries to other areas discharge from the inflamed earlobe was found to contain toxin- do occur. Rings in nipples may be torn out. Higgins et al. [42] producing S. aureus. Piercings traversing the auricular cartilage reported a patient with urethral rupture following avulsion of may also produce infection, particularly if a piercing gun is a Prince Albert ring. Wilcox [43] expresses concern that penile used. This was the case for a 14-year-old girl whose ear re- piercings may increase the chance of tissue destruction in the quired incision and drainage (I&D) [54]. Cultures of the drained sexual partners of those with piercings.
material yielded Staphylococcus species and Pseudomonas aer- Body jewelry may become an issue in radiology, as it may appear as a peculiar artifact if the patient is unwilling or unable P. aeruginosa has also been reported to occur in others when to remove it [44]. Reichle and Dailey [45] point to the potential ear piercings involve the auricular cartilage. Turkeltaub and for airway obstruction due to the edema associated with tongue Habal [55] reported a case of acute chondritis following ear piercing. Price and Lewis also express concern about problems piercing. A 16-year-old girl required I&D for an abscess that with piercings in oral sites, including airway obstruction, chipped had failed to respond to cefadroxil after her ear piercing. She or cracked teeth, and interference with mastication [46].
had initially sought treatment for erythema, swelling, and ten-derness at the site of the piercing. A 45-year-old Italian womanfound that her ear became swollen and tender following place- Infectious Complications
ment of an acupuncture staple, similar to an earring, in the Infections following piercing have been reported infre- pinna for weight loss [56]. Green discharge was seen and quently in the medical literature. Cortese and Dickey [21] found P. aeruginosa was isolated in culture. The patient required that 11% in a survey of student nurses with pierced ears had surgical I&D and was left with some deformity. A 13-year-old infection with purulent discharge. Biggar and Haughie [8] also required I&D after developing infection of the high exter- found that 24% had infection with purulent discharge. An or- ganism may be introduced to the piercing site at two points in P. aeruginosa infections of the ear have been reported to time. The first is when the piercing is done with poor technique require substantial resection of necrotic tissue. This was the and unsterile instruments. The second is during the aftercare case in a 20-year-old woman presenting to an emergency de- of the piercing site, when the wound is not kept clean or is partment 2 weeks after undergoing a piercing through the auri- cle [58]. She had pain and discharge, which were treated empir- Some bacterial infections, like those reported by Scully and ically with oral dicloxacillin. When she returned several days Chen [48] of pierced tongues requiring the expression of puru- later with no change in her symptoms, I&D was performed lent material, will spontaneously heal. A nipple piercing that with removal of necrotic tissue, which resulted in cosmetic resulted in an abscess of the left breast was reported by Fiumara deformity. Irrigation and debridement, with administration of and Capek [49]. The abscess responded to ampicillin therapy.
intravenous ceftazidime and ciprofloxacin, cleared the infec- Some infections have required surgical irrigation and debride- tion. Cumberworth and Hogarth [59] reported P. aeruginosa ment. With treatment, most bacterial infections will heal, but infection in a woman who presented with pain and a large because of the intimate nature of some piercings, or because abscess after her upper ear was pierced with an ear-piercing of fear, some patients will not seek timely medical advice.
gun. She required resection of a large portion of the upper ear.
Staphylococcus aureus is the organism most often reported Also reported with some frequency and sometimes leading with regard to infected piercings. It was the predominant organ- to life-threatening outcomes after body piercing are infections ism recovered from a group of girls who had held a ‘‘piercing due to group A b-hemolytic streptococci (GABHS). Jay [26] party’’ in a children’s home [50]. Lovejoy and Smith [51] reported infection with GABHS in a series of children seen in described three patients whose blood cultures were positive for a clinic. A 17-year-old boy was seen following an ear piercing that resulted in a cutaneous infection at the piercing site. This reported in the medical literature beyond a few case reports led to septic arthritis and acute glomerulonephritis [60]. Culture about non-ear sites, it is probable that health care providers of a joint aspirate and discharge from the ear yielded GABHS.
will be called on to treat complications resulting from the George and White [61] reported a woman who attempted to practice. Piercings may also be of concern for emergency ser- repierce an infected ear lobe. She became toxic and presented vices personnel, as the jewelry may cause obstruction or be in shock. Blood cultures were positive for GABHS, and the patient developed bronchopneumonia and acute renal failure.
Patients may be reluctant to seek medical care because of After a protracted hospital course and a long convalescence, the potential for embarrassment about a piercing. The health care provider should obtain a history of piercing, particularly Erysipelas has been reported after ear piercing [62]. Also when presented with unexplained hepatitis, endocarditis, or reported with infection due to GABHS is endocarditis; a nose other syndromes for which piercing may be a risk. To be most piercing resulted in endocarditis in one young woman [9], and effective, this must be done in a nonjudgmental fashion. No a 15-year-old boy developed a ventricular septal defect from patient wants to be made to feel a deviate or unacceptable endocarditis that followed an ear piercing [63].
for having a nonmainstream body piercing, particularly when Other bacteria have the potential to be inoculated at piercing sites. Primary tuberculosis was inoculated into the earlobe of Several cases in this review required second hospital admis- an 18-month-old child by a mother with active pulmonary sions because of failure of antibiotic therapy. These complica- tuberculosis [64]. The child’s tuberculosis was localized to the tions may be minimized by culturing specimens from the in- area around the ear and neck. Ear piercing has been reported fected site for organism identification and determination of as a method of inoculation of Clostridium tetani in India and appropriate antibiotic therapy. Removal of the jewelry, acting Senegal [65]. Thorner cites cases of death due to tetanus follow- as a foreign body, may be required to cure local infection.
Body piercing will continue, so prevention of infection must Viruses may also be inoculated in the course of piercing.
be of concern. Many bacterial infections have been shown to Transmission of HBV has been well documented in cases in occur following piercing, and the risk of hepatitis B and C has which needles and other equipment have been shared in body been associated with piercing. Although no cases have been piercing as well as tattooing [1, 66] and in association with reported in the medical literature, it is possible that HIV may finger-stick devices and acupuncture [13, 15, 67]. In a large also be transmitted through unsterile, shared piercing tools [79 – retrospective Italian study [68], ear piercing was significantly 81]. Transmission of HIV has been shown to occur with acu- associated with hepatitis, even when intravenous drug use and puncture treatments [82]. Of concern is the lack of regulation multiple sex partners were controlled for (OR Å 2.20; 95% of those who perform body piercings and the facilities they CI, 1.51 – 3.22). A case-control study in the state of Washington found that those having HBV were significantly more likely Several states have enacted legislation to regulate both tat- (P õ .001) to have had their ears pierced than controls [69].
tooing and body piercing. A bill (AB186) is pending in Califor- Karim et al. [70] found that HBV seropositivity in females was nia that would require practitioners of tattooing and body pierc- significantly associated with ear piercing (P õ .001) among ing and those applying permanent cosmetics to be registered black urban children in South Africa.
with the county in which they practice.
Van Sciver [71] reported a patient with hepatitis in whom Those in these businesses would have to comply with mini- the only identifiable risk factor was having had her ears pierced mum health and safety guidelines, pay licensing fees, and sub- 3 months prior to development of symptoms. A patient with mit to inspections and fines by county health departments. It acute HBV seen at Massachusetts General Hospital (Boston) is hoped that regulation will reduce the potential for infectious was thought to have been exposed to the virus through ear complications of body piercing and tattooing. The Association piercing [72]. This case resulted in severe hepatic necrosis of Professional Piercers [20] supports the standardization in and death after a long hospital course. Another case of HBV safety and piercing practices. Piercings done with a maximum infection, reported by Parry [73], followed ear piercing; no of care will reduce the number of infectious complications that other risk factors were identified, and the infection resulted in Body piercing [74] and tattooing [75] have been demon- strated to be risk factors for the acquisition of hepatitis C virus, References
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