|Complications of Body Piercing|
Complications of Body Piercing
Stephen C. Ross, M.D.
A 15-year-old female presented to the office with pain and swelling around a navel piercing that she had received two weeks earlier. The piercing was done at an established business, but was without parental consent. Shortly after the piercing the patient noticed some swelling around the site but was afraid to tell her parents. She tried to clean the area with hydrogen peroxide, but noticed that the area was becoming more painful. On examination there was a piercing through the superior aspect of the navel. Erythema and induration was found at the piercing site. There was a purulent drainage. The patient was reluctant to remove the piercing, and she was started on cephalexin 500 mg three times per day with topical antibiotic twice per day. Within seventy-two hours the induration and purulent drainage had decreased. The patient subsequently removed the navel ring at the urging of her parents and had complete healing.
The incidence of body piercing has increased substantially over the last ten years. Although for many years piercing other than ear piercing was confined to the youth counterculture, now navel, tongue, and genital piercing has been incorporated into the mainstream population. Complications of body piercing are now becoming common reasons for visits to primary care physician offices. The incidence of complications of body piercing is hard to quantify, since patients are often too embarrassed to seek medical attention. Fear of embarrassment may actually increase the severity of a complication.
Sites of Piercing
To better understand the medical complications of body piercing one needs an appreciation of the different body sites that are used for piercing. Traditionally, piercing has involved the ear lobe but recently more non-traditional sites have been used. These include high ear piercing involving the cartilage, piercing the ear tragus, nostril piercing, piercing of the septum of the nose, eyebrow piercing, piercing of the tongue, piercing the lips, and nipple and navel piercing. Genital piercing has also become more common with specific names of historical significance.1
A piercing gun is frequently used by physicians and department stores for ear piercing. The gun consists of a spring-loaded action, which pierces the ear lobe. The piercing gun can only be used for ear lobes. For other body sites a needle of some type is used which matches the size of the jewelry that will be used. The jewelry most commonly used at sites other than the ear consists of a barbell-shaped ornament, a ring with a bead or a stud with a metal ball at one end or a tusk.
Data relating to medical complications of body piercing is hard to find. Most data focus on ear piercing. Minor complications can occur in about 20% of individuals, with major complications occurring in about 3% of individuals. The complications consist of redness, swelling, drainage, infection, bleeding, cyst formation, large scars, trauma, and tear.1
After local irritation, the most common complication of body piercing is local bacterial infection as seen in this case report. Incidence of skin infection ranges from 11% to 24%.2 Infectious organisms may be introduced at two different times during the piercing process. The first is if the piercing is done under non-sterile technique or with poor equipment. The second is during the aftercare if the wound is not kept clean. Simply having any foreign body in skin tissue can raise the risk of infection.3
Staphylococcus aureus is the most common bacterial organism found in infected piercing sites. This organism has been isolated in local skin cultures, blood cultures, and cerebral spinal fluid cultures.2 P. aeruginosa has also been reported to be isolated from infected ear cartilage. Usually, infections with P. aeruginosa are more virulent and require intravenous antibiotics and surgical drainage.4 Life-threatening infections with beta-hemolytic streptococci (GABHS) have also been reported. One case resulted in the development of beta hemolytic septic arthritis after a cutaneous infection of an ear-piercing site in a 17-year-old boy. Eventually, the patient developed glomerulonephritis.5
Viral infections have also been documented to occur after body piercing, particularly when punch-style equipment is used with non-sterile technique. Needle sharing without sterilization will also increase the incidence of infection. The most common transmitted virus is hepatitis B. Hepatitis C transmission has also been documented in body piercing as well as tattooing.1,2 One case of a possible transmission of HIV from body piercing has been reported without any other known exposure to the virus.6
Finally, rare infectious diseases such as bacterial endocarditis, primary tuberculosis and Clostridium tetani have all been reported in the literature following body piercing.2 Recently, Dyce et al reported a case of a women who developed a rare form of tetanus called cephalic tetanus caused by wounds of the head and neck. She had had her tongue pierced three weeks earlier and had a complete series of tetanus as a child but no booster within five years. As a result of the disease, she had permanent facial muscle weakness.7
Metal Associated Problems
Contact dermatitis from metal allergy associated with ear piercing has been reported.8 Nickel allergy is the most common, and, in one case, the allergy was so severe that the patient developed asthma after having her ears pierced with a nickel substance. The metals leading to allergy have been nickel alloys or thin plaiting over nickel alloys.9 The rash related to an allergy to nickel presents as an eczematous rash.
An allergy to gold jewelry can present as lesions, which look like granulomas or lymphocytomas.9 These gold allergy lesions can be treated either with excision or local steroid injection. Silver jewelry has been found to cause silver poisoning in body piercing. The skin can become discolored from the leeching of silver salts. The discolored area needs to be surgically excised.9
Many types of trauma have been associated with body piercing. Torn ear lobes and other traumas have been associated with pierced ears. Rings in nipples may be torn out. One patient had a urethral rupture following avulsion of a penile piercing. Locally after piercing a hematoma or tissue edema may occur. Sometimes these traumatic injuries will require surgical repair.
Embedded jewelry is another complication reported with piercing. Ear piercing guns can cause the earrings to be deeply embedded in the ear lobe. The earring back may also become embedded in the earlobe if the jewelry is placed too tightly under high pressure. If the embedded jewelry cannot be removed easily, surgical excision under local anesthesia may be necessary.
Piercing of the tongue and lip area has increased in popularity over the last several years. These piercing sites present with their own set of complications and problems. In a study by Boardman and Smith, they found that in 51 patients with tongue piercing thirteen reported damage to the teeth in the form of chipping, four reported gingival injury, eight demonstrated a noticeable increase in salivary flow, and two reported an infection.10 Price and Lewis found that oral piercing might cause airway obstruction as a result of post-piercing edema of the tongue or aspiration of the device. The tongue devices can interfere with speech and mastication. Infection is at a high risk because of the high concentration of bacteria in the mouth. Other problems have included hypersensitivity to the metals, and incursion of foreign bodies such as food debris into the pierced site.11 Boardman and Smith found that complications to lip piercing included gum injuries, increased salivary flow, and trauma to the lip area.12
Besides the complications mentioned above, other problems have been associated with body piercing. Scars and keloid formation have frequently been reported especially in ear lobe piercing. Keloids have a higher incidence in blacks and Asians. As the practice of piercing has increased in men, keloids have been on the rise in this population. Treatment includes intralesional cortisone injection, surgical excision, and intralesional verapamil.13 Slawik reported a case of priapism that resulted from a scrotal piercing.14
There are case reports of sarcoidal-like granuloma formation at piercing sites particularly with gold jewelry. Epidermal cyst formation has been reported and is felt to arise from the penetration of an epidermal cyst into the dermis during the piercing procedure.10 Pseudolymphoma or lymphadenopathy may also occur with piercing.2
Body jewelry may cause problems with radiology. If the patient is unable or unwilling to remove the jewelry it may cause an artifact or obscure a potential finding.
Psychologically, physicians should be aware that body piercing might be a variant of self-mutilation. Multiple body piercing has been associated with individuals who have suffered some form of physical or sexual abuse in the past.
The prevention of body piercing complications is difficult. Although some states have initiated laws to regulate body piercing, most legislation is ineffective. Most of the individuals who perform body piercing are self-trained. Any type of training on sterile technique or proper instrument preparation is sorely missing.
To reduce the incidence of infection, individuals performing body piercing should follow aseptic surgical techniques. The jewelry should be selected that is proper for the site being pierced. Once the jewelry is selected then a single-use nonreusable setup should be used to perform the piercing. A piercer should wear examination gloves and change them between procedures. Proper aftercare instructions should be given to and followed strictly by the client. If an ear-piercing gun is used, the earrings must be sterile and the piercing gun appropriately cleaned and sterilized. Tight clothing should not be worn around freshly pierced sites.
The prevention of hepatitis B infection from piercing can be improved with the vaccination of all children and adolescents.
Patch testing can identify metal-sensitized individuals. Using surgical-grade steel, solid 14K or 18K gold or other high-grade metals such as titanium or platinum will decrease skin reactions. Also metals can be tested for the presence of nickel, the most highly allergic element.
Encouraging individuals to seek medical attention at the first sign of infection or skin reaction will help to reduce serious complications of body piercing.
Body piercing will continue and is definitely on the rise. Physicians should be aware of the complications listed above. Patients may be reluctant to seek medical care due to fear of embarrassment about a piercing, thus leading to potential serious complications. When seeing a medical problem related to piercing, the practitioner should be non-judgmental so as not to frighten the patient into delaying care even further. As states enact more legislation to regulate the body piercing industry, hopefully, the complication rate will go down.