Tatuajes Y Body Piercing

Tattooing and body piercing

Authors R Michelle Schmidt, MD, MPH Myrna L Armstrong, RN, EdD, FAAN Section Editor Amy B Middleman, MD, MPH, MS Ed Deputy Editor Mary M Torchia, MD Last literature review version 17.1: January 2009 | This topic last updated: October 6, 2008 (More) INTRODUCTION — Many health care professionals associate body art with criminal activity or psychiatric disturbance, based in part on some early descriptive studies [1-3] ; some are still trying to make that case [4,5] . Individuals often associate tattoos and body piercings with gang members, prisoners, military personnel, or rebellious teenagers [4,5] . In reality, however, a variety of people, including professionals, clergy, or other "respected members of society" acquire body art for an assortment of reasons. Unfortunately, a health care professional's negative attitude about body art may interfere with the optimal treatment of patients with these types of ornamentation [6-8] . The history and health hazards associated with tattooing and body piercing will be reviewed here. HISTORY — Both tattooing and body piercing have been prevalent for thousands of years in a variety of cultures. Tattooed mummies from Egypt, Peru, and the Philippines have been radiocarbon dated as far back as 2000 BC [9] . The word tattoo is derived from the Tahitian word "ta-tau," which means "the results of tapping" and describes the raking process by which the Polynesians applied their tattoos. Historically, the Japanese have used hand-held, nonmechanized instruments to apply intricate tattoos, which often cover large portions of the body. Polynesia and Japan are believed to be responsible for the introduction of modern tattooing into Western cultures via the exposure of European and American sailors to these practices while on commercial or naval visits [9] . Body piercing also has a long history, with rumored reports of Roman centurions wearing nipple rings in their breast plates to hold their capes in place and as a sign of loyalty to their Emperor [10,11] . The Mayans are believed to have pierced their tongues as part of spiritual rituals [10,11] . Queen Victoria's husband, Prince Albert of Saxe-Coburg and Gotha, also is rumored to have had his penis pierced, although the veracity of this assertion is unproven [6,9,11] . EPIDEMIOLOGY — Information regarding the prevalence of tattooing and body piercing among adolescents and young adults continues to be published, and the numbers show progressively increasing amounts of body art, which has become mainstream among individuals aged 16 to 25 years [12-19] . In one cross-sectional, convenience sample of 2101 adolescents in 1995, 10 percent had tattoos [20] . Data from surveys of high school and college

students (13 to 25 years of age) indicate a prevalence of 25 to 35 percent for body piercing (excluding traditional earlobe piercing in males and females) and 15 to 25 percent for tattooing [13-15,21,22] . Nearly one-half of 225 adolescents surveyed at an urban, hospital-based adolescent clinic reported piercings (earlobe piercings were excluded in females but not males; 58 percent of respondents were African American and 30 percent were Caucasian) [16] . In a secondary analysis of survey data in 2002 from a nationally representative sample of 6702 adolescents (11 to 21 years of age), 4.5 percent of adolescents had permanent tattoos [5] . A 2003 survey of 1010 people conducted by Ohio University found that one in every seven adults has a tattoo, with young adults about 10 times more likely to have one compared with their parents [23] . In a 2007 Pew Research Center report examining body art, 36 percent of 18- to 25-year-olds and 40 percent of 26- to 40-year-olds have at least one tattoo [24] . Although tattooing and body piercing have been associated with risk-taking behaviors, the population sampled appears to affect the behaviors associated with body art [4,5] . In adolescent clinics, tattooing was significantly and independently associated with other highrisk behaviors including sexual intercourse (in 83 percent of the tattooed versus 36 percent of the nontattooed adolescents), binge drinking (78 versus 45 percent), smoking (63 versus 25 percent), marijuana use (38 versus 12 percent), fighting (54 versus 40 percent), inflicted injury (38 versus 17 percent), gang membership (14 versus 4 percent), truancy (60 versus 26 percent), and school failure (50 versus 29 percent). In a smaller survey (484 adolescents), tattooing and body piercing were associated with disordered eating behaviors, gateway drug use, hard drug use, sexual activity, and suicide [4] . In another study, college students with tattoos as well as those with body piercings reported substantively and significantly greater frequency of premarital sexual activity than nonpierced and nontattooed college students [25,26] . Other studies of college students have not found an increased frequency of high-risk behaviors among tattooed youth [14,21,22] . Students with and without body art shared similar demographic characteristics such as natural parent households, positive family relationships, parents with college degrees, daily prayer habits, and moderate to strong religious faith [27] . Another survey of undergraduates at a large southwestern public university found little correlation between tattooing behavior and religious beliefs [28] . Motivational factors — A number of motivational factors have been suggested: The desire to experiment with body art may be a normal developmental drive for some adolescents, a means to redefine themselves, and take control of their bodies and their identities. Friends provide major support for the body art. In one study, the magnitude of a friend's influence was about double that of the family's, whether the friends have or do not have body art themselves [29,30] . Among adolescents, body art may be viewed as normative [16] . A means of making themselves feel unique [20-22,27,29] . Body piercing is sometimes used as a means of injury during self-mutilation [31] . THE TATTOOING PROCESS — Most tattooing is done in commercial studios, although studio artists may establish temporary locations (flea markets, rock concerts, and fraternity parties) [32] . The former is preferable because the likelihood is greater that the tattoo will be applied using sanitary techniques. Although tattoo artists often refer to themselves as professionals,

very few complete apprenticeships and there is no standardized procedural curriculum. Artists routinely learn their trade either by self-teaching or by observing others. Few states require examinations and continuing education about anatomy, universal precautions, disease transmission, skin diseases, sterilization procedures, sanitation, personal hygiene, or after-care instructions [33] . Unlike hair stylists and nail technicians, who complete a structured curriculum (yet do not perform invasive procedures), tattoo artists are not required to complete any formal training, even in states that require examinations. Commercial tattoo artists place the tattoo into the skin using a hand-held electric-powered machine. This device is held several centimeters away from the skin and functions like a sewing machine with a needle bar moving up and down between 50 to 3000 times per minute [34] . Several needles may be attached to the end of the needle bar and are responsible for inserting the pigment into the skin. The artist uses different numbers of needles for the desired artistic effect. As examples, a single needle can create a fine line, a group of fourteen needles can fill in color, and smaller groups of needles can create thicker lines or shading. The skin is repeatedly punctured using the solid bore needles to allow the tattoo pigment to leach into the dermis, where it is taken up by macrophages [9,35] . The depth of the puncture varies from 1 to 4 mm [34] . During the tattooing process, blood and serosanguinous fluid seep onto the skin and are wiped away by the artist [9] . The client often chooses a design from numerous illustrations on display at the studio or provides the artist with an illustration of the desired tattoo. Before the tattoo is actually placed, the skin should be cleaned with an alcohol and iodine solution. The design is then drawn on the skin by hand or with a stenciling machine. Ink is applied to the design by dipping the needles into disposable ink cups before application to the skin. Afterwards, petroleum jelly or a similar substitute is applied to the skin to prevent oozing of serosanguinous fluid. After the tattoo has been applied, the artist bandages the tattoo and should provide after-care instructions, including recommending that the client cleanse the site twice daily with an antimicrobial soap and avoid contact with the site except for cleaning [9,34,35] . Amateur tattoos are often applied or placed by friends or acquaintances in an unclean environment. These tattoos often have crude designs and are placed using primitive instruments such as pencils, pens, or other sharp objects. The pigments also are unconventional and may incorporate available materials such as charcoal, ink, or mascara. Adolescents may obtain amateur tattoos because they cannot find a studio that will tattoo minors or because they cannot afford professional tattoo rates [34] . PIERCING TECHNIQUES — Body piercing also may be performed by either a commercial or an amateur artist; most body piercing is performed in tattoo studios [33] . Fewer states have regulations for body piercing than for tattooing. As with tattooing, the skin is cleansed with an alcohol and iodine solution before it is pierced. No topical or local anesthesia generally is applied. For earlobes, the equipment used depends on the type of piercing establishment. Studio piercers use regular straight, sterilized needles, usually a 12- to 16-gauge hollow-bore needle. After the hole has been established, jewelry is guided through the hollow-bore needle using a string or wire. Before piercing is performed, the client selects both the body part to be pierced and the jewelry for the piercing site. Jewelry

is typically made of 300 grade surgical steel, niobium, titanium, or gold to prevent contact dermatitis. The piercer should give the client after-care instructions for cleaning and maintaining the piercing site; these instructions are similar to those for tattooing and include cleansing of the site twice daily with an antimicrobial soap and reminding the client to avoid contact with the site except for cleaning [10,36,37] . Complications can occur any time after the piercing when serosanguinous fluid and blood are released with these puncture wounds. Ear lobe or high-rim piercings also are frequently performed at commercial establishments and kiosks in shopping malls. Many of these establishments use a "cartridge-loaded" gun that contains the earring stud and some continue to use "spring-loaded" guns that can produce trauma around the opening. These establishments are popular because they do not charge for the piercing procedure, although the customer may be strongly encouraged to buy the "aftercare solution." (See "Localized infection" below). In Western cultures, the earlobe has been the traditional and most accepted site for piercing. However, many other parts of the body, including the tragus or the helix of the ear, the eyebrow, nasal septum, or the ala of the nose, have become popular [31] . The lip can be pierced, as can the tongue and navel. Less traditional piercings may be performed in the uvula, cheek, chest, neck, and knuckles. Insertion of plastic and wood plugs (3-D inserts) or "pocketing", where the ends of the piercing jewelry are embedded into the skin leaving the middle of the shank exposed (show picture 1), also may be seen. Genital and nipple piercings (clitoral, clitoral hood, labial, perineal, penile, and scrotal) (show table 1) are being obtained more frequently in the young adult population [11,12,15,31,36-39] . A survey of individuals with intimate piercings provides information regarding the demographics, motivations, and health concerns of individuals with intimate body piercings [38] . Health concerns included aspects of pregnancy and lactation [40,41] . According to the LaLeche League (www.LaLecheleague.org), women with healed nipple piercings can breastfeed [40] . Whether the jewelry is left intact during breastfeeding depends on the type of jewelry and the "latch on" of the infant. Amateur piercing is similar to amateur tattooing. Often, it is performed by oneself or friends using crude instruments in a variety of environments, which can lead to infection [10,36] . The navel is the most common self-pierced site. Amateur piercing may lack the proper technique and depth, leading to rejection of the jewelry from the skin. The jewelry may be pushed out of the skin because of the formation of scar tissue. RISKS — The risks associated with tattooing and body piercing can be divided into purchase risks, possession risks, and health risks [20,34,42] . Purchase risks — Purchase risks surround the purchase of a tattoo or piercing, including expense and pain. Impulsive purchasing of a product, such as when a teen quickly makes a decision in favor of a tattoo, can lead to purchase risks. Teens may overpay for body art, endure pain during the procedure, and experience infection from the body piercing because they did not know about the importance of skin care. Adolescents tend to have high purchase risks.

Possession risks — Possession risk refers to the risk of a negative response from others when the specific tattoo or body piercing is noticed. Although the tattoo or body piercing may have significant meaning to the adolescent, parents, teachers, and others frequently express displeasure with it. Thus, the tattoo or piercing has a risk associated with potentiating low selfesteem. Possession risks may become the motivation for tattoo removal if, over time, the tattoo's symbolization of uniqueness or identity becomes a stigma, focus of negative comments, or problems with clothes [43] . Health risks — Both tattooing and body piercing are associated with health risks, yet the medical literature lacks data on the incidence of these dangers compared with the overall incidence of body art in the United States [32] . This lack of data is a result of infrequent reporting of complications to state health departments or in the medical literature, rather than an infrequency of complications. Most health risks are related to infectious complications or localized skin reactions, but the potential of blood borne diseases is present. As an example, one study of 766 college students with body art reports infection at the piercing site (45 percent), localized skin reaction (39 percent), and two cases of hepatitis [15] . In other surveys of university undergraduates, the incidence of medical complications was 17 to 19 percent among the students with body piercings (including bleeding, tissue trauma, and infection). There were no reported medical complications of tattooing [12,44] . In a survey of 225 adolescents at an urban hospital-based adolescent clinic, complications of body piercing included infection (74 percent), bleeding (30 percent), allergic reactions (26 percent), bruising (19 percent) and keloids (19 percent) [16] . Even ear lobe piercings can be a problem. In a retrospective review, embedded earrings accounted for 25 in 100,000 patient visits to a pediatric emergency department between 2000 and 2005 [45] . The median age was eight years, 87 percent involved embedded earrings in the ear lobe, and 68 percent involved the posterior portion of the earring. These cases support the American Academy of Pediatrics recommendation that ear piercing be avoided until self-care is achievable [46] . Localized infection — The most common infectious complications of body piercing, especially navel and ear piercing, is a localized skin infection caused by Staphylococcus aureus and Pseudomonas aeruginosa [12,35,37,47-50] . The risk of infection is greater in individuals with newly acquired tattoos and body piercings because of diminished skin integrity from procedures especially done in warm-weather months [47] . Several outbreaks of community associated methicillin resistant S. aureus (CA-MRSA) among tattoo recipients were reported in communities in Ohio, Kentucky, and Vermont during the time period June 2004 to August 2005 [51] . A total of 34 primary cases and 10 secondary cases (amongst persons living in the same house or with close personal contact) were identified. Investigation by the Centers for Disease Control and Prevention (CDC) found that although gloves were worn by all tattooists, adherence to other infection-control measures (eg, changing gloves between clients, hand hygiene, skin antisepsis, disinfection of equipment and surfaces) was not practiced. In addition, three of the tattooists associated with outbreaks

had been recently incarcerated, a known risk factor for MRSA infection. (See "Epidemiology and clinical spectrum of methicillin-resistant Staphylococcus aureus infections in children"). High-rim piercing is a particular problem because of the lack of vascularity [47] . Reports of auricular chondritis, including an outbreak caused by Pseudomonas aeruginosa, associated with the use of spring loaded piercing guns have been published [48,52-54] . Another case involving 15 young people requiring surgical treatment and multiple antibiotics from contaminated aftercare solution was reported [49] . (See "Other Pseudomonas aeruginosa infections", section on Perichondritis). The risk of infection can be reduced when the individual receiving the tattoo or piercing understands the procedure, obtains it in a studio that uses sterile procedures, and follows appropriate after-care instructions regarding cleaning and maintenance. We suggest soap and water as an appropriate after-care solution. Some piercing establishments in shopping malls sell benzalkonium chloride as their after-care product of choice. However, benzalkonium chloride does not have adequate microbicidal activity against P. aeruginosa. In addition, it may be contaminated with other microorganisms [48,49] . Most piercers recommend that the jewelry not be removed, even with a localized infection, to allow the piercing site to maintain an outlet for drainage. Healing times for body piercing vary according to site, but can take as long as one year for navel piercings and certain genital piercings and up to six weeks with ear piercing and other facial or oral piercings (including tongue piercings) [11] . Systemic infection — Systemic infection complicates tattooing and body piercing less commonly than does local infection and is also more likely to occur in people who have had amateur tattoos or body piercing or who have not followed the after-care instructions. Cases of tetanus [55] , acute post-streptococcal glomerulonephritis [56] , streptococcal septicemia [57] , staphylococcal toxic shock syndrome [58] , and pseudomonal abscesses [59] have all been documented after body piercing. A case of a mixed oral flora cerebellar abscess was reported four weeks after tongue piercing in a patient who developed an early local infection in the tongue and removed the jewelry within six days of the piercing [60] . In the past, syphilis was transmitted by tattooists who held the needles in their mouths or used saliva to mix pigments [35,50] . (See appropriate topic reviews). Infective endocarditis — Since 1991, more than 22 cases of infective endocarditis (IE) associated with body art in adolescents and young adults have been described in the national and international literature; one case resulted in death [61-85] . Although the actual number of body art procedures performed in this time frame is unknown, it is on the order of millions per year, suggesting that the risk of IE is exceedingly small. Tongue piercing is the most commonly involved site; other sites include the ear lobes, navel, and nipple. One case occurred in an individual with frequent tattooing during a five-year period [65] . The cases have occurred in patients with a history of congenital heart disease (CHD) as well as in previously healthy individuals. Various organisms have been involved, including methicillin susceptible Staphylococcus aureus [61,63,65,69,72] , methicillin-resistant S. aureus [66,68] , S. epidermidis [62] , Streptococcus viridans [70] , Haemophilus parainfluenzae [67] , H. aphrophilus [64] , and Neisseria mucosa [73] .

Healthcare providers should consider the possibility of IE in any patient who presents with unusual clinical events (eg, unexplained fever, rigors, weakness, myalgia, arthralgia, lethargy, or malaise) between one week and two months after tattooing or body piercing [72,86] . As body art continues to be a mainstream activity, proactive education about the risk of infection is recommended for parents and children. Education about the possibility of IE should be extended into the community to include body artists since many adolescents may return to the body artist before the health care provider if infection occurs [20,32,34,84] . The American Heart Association does not recommend prophylactic antibiotics for patients with CHD before obtaining body art (tattoos or body piercings) [87] . However, it has been suggested by several clinicians who have cared for patients with CHD who developed IE after body art [63,86-89] , including 61 percent of the physician members of the International Society of Adult Congenital Cardiac Disease (ISACCD), 57 percent of pediatric cardiologists in 16 medical centers in the United Kingdom, and 28 percent of the Japanese Circulation Society Joint Working Groups for Guidelines for Management of Infective Endocarditis [88,90,91] . (See "Antimicrobial prophylaxis for bacterial endocarditis"). The diagnosis and treatment of infective endocarditis are discussed in detail separately. (See "Diagnostic approach to infective endocarditis" and see "Antimicrobial therapy of native valve endocarditis" and see "Antimicrobial therapy of prosthetic valve endocarditis"). Hepatitis — Hepatitis B and C can be transmitted during either tattooing or body piercing via reused or inadequately sterilized instruments; however, the actual risk for these infections among individuals with body art is not known [92] . In one study of 626 adults, hepatitis C seropositivity was increased among those who had a tattoo from a commercial tattoo parlor (odds ratio 6.5, 95% CI 2.9-14.8) [93] . Hepatitis B is especially worrisome because it is highly contagious, even with minimal blood exposure, and because state regulations do not require hepatitis B immunization for tattoo artists and body piercers [33,35,94] . (See "Epidemiology; transmission and prevention of hepatitis B virus infection" and see "Epidemiology and transmission of hepatitis C virus infection"). HIV infection — Many health care providers consider tattooing or body piercing to be a risk factor for HIV infection. In the United States, no clearly established cases of HIV infection caused by these practices exists [35,37,50] . Although HIV may be transmitted through either of these methods, the relationship needs to be more clearly defined. Certainly the risk of contracting either hepatitis or HIV can be reduced by using new needles with each piercing or tattooing and by selecting a studio with an educated artist. (See "Epidemiology of pediatric HIV infection", section on Risk groups for HIV acquisition). Skin reactions — Generalized skin reactions such as acquired hypersensitivity reactions to either the tattoo pigment or the jewelry used in piercing can occur [95] . Tattoo pigments are not FDA approved for intradermal use and contain nonstandardized ingredients. In one study, samples of 30 tattoo inks were chemically analyzed and results compared with the information supplied by the manufacturer [96] . Among the 30 pigment samples, the most commonly identified elements were aluminum (87 percent), oxygen (73 percent), titanium (67 percent), and carbon (67 percent). The elemental analysis was usually consistent with the information supplied by the manufacturer, but there were important exceptions. Further research indicates that some pigments are industrial grade colors suitable for printers' ink or automobile paint [97,98] . Most tattoo pigment manufacturers do not provide a description of

the enclosed materials, but one state (California) requires that tattoo pigments provide an itemization of ingredients [33] . (See "Overview of dermatitis"). Hypersensitivity reactions — Hypersensitivity reactions have been reported in association with red (mercury), green (chromium), yellow (cadmium), and blue (cobalt) tattoo pigments [35,99] . Hypersensitivity reactions also have been reported after the use of henna (para-phenylenediamine) for temporary tattoos [95,97,100-105] . The addition of paraphenylenediamine is "highly sensitizing" and is known to create scarring in some children; temporary tattooing does not fall under the review of the FDA [104] . Referral to an allergist may be warranted for patients who develop severe local reaction to tattoo pigments or henna and are determined to proceed with tattooing since these patients may be at increased risk for serious systemic hypersensitivity reaction. Hypersensitivity reactions from body piercing can be avoided by using jewelry that is made of 14K gold, surgical stainless steel, niobium, or titanium [11] . Less common skin reactions that may occur with either piercing or tattooing include sarcoidal reactions, scleroderma, keloid formations, and hypertrophic scars [35,106-111] . Keloids — Keloids are benign fibrous growths present in scar tissue that form because of altered wound healing. In one survey of 32 patients with keloids related to ear piercing, keloids were more likely when earlobes were pierced at or after 11 years of age than before 11 years of age (80 versus 24 percent) [112] . The authors suggest that post-menarcheal patients with a family history of keloids be counseled to avoid ear lobe piercing to avoid the cosmetic concerns and lowered self-esteem that may result from keloid formation. (See "Keloids"). Other reactions — Tattooing over a melanocytic nevus can make surveillance for changes suggestive of melanoma difficult [113] . (See "Acquired melanocytic nevi (moles)", section on Surveillance). Oral complications — Dentists and clinicians should be prepared to manage the oral complications of tongue and lip piercing [114] . A high incidence of gingival recession secondary to gingival trauma has been reported with lip piercing [115,116] . Other potential complications include difficulty maintaining adequate oral hygiene, which combined with mechanical trauma, may lead to localized periodontitis [117-120] ; increased salivary flow [118] ; chipping, cracking, and fractures of the teeth [118,121,122] ; interference with mastication and swallowing [123] ; and speech impediments [114,124] . (See "Overview of gingivitis and periodontitis in children and adolescents" and see "Evaluation and management of dental injuries in children"). One study evaluated the effect of duration of tongue piercing and length of the barbell stem on gingival recession and tooth chipping in 52 adults with tongue piercings [125] . Dental effects were directly related to duration of piercing. No subject with piercing less than two years had gingival recession or tooth chipping; 50 percent of subjects who wore barbells for more than two years had gingival recession on the lingual surface of the lower central incisors; and 47 percent of subjects with piercing for more than four years had tooth chipping of the molars and premolars. The barbell length affects the rate of recession and chipping differently; the rate of recession is increased with long barbells and the rate of chipping is increased with short barbells.

Controversy remains both in the emergency medicine and anesthesia literature about the removal of oral piercings during anesthesia [126] . Other complications — A variety of other complications can occur depending upon the site of the piercing or tattoo. Aspiration of either oral or auricular jewelry is a valid concern, particularly among young children and those who play contact sports [127,128] . Tongue swelling and edema can lead to airway obstruction [129] . Case reports of prolonged priapism and recurrent condyloma acuminata have been reported with penile piercings [130,131] . A case of hyperprolactinemia associated with bilateral nipple rings has been reported [132] . Prolonged bleeding after tongue piercing may lead to hypotensive collapse [133] . Friction from clothes and shearing forces during physical activity can produce abrasions [114,134] . The presence of nonstandardized ingredients in tattoo pigments may produce difficulties with radiologic imaging. Burning sensation and intense pain over tattooed sites that contain heavy deposits of metallic oxides or iron or titanium have been reported. These particles may act as conductors during magnetic resonance imaging [135] . At least one author has recommended that patients be screened for tattoos as part of their medical history before undergoing radiographic procedures [136] . Jewelry remaining in the mouth can limit radiographic evaluation by scattering radiation and obscuring visualization of oral injuries [114] . The presence of lumbar tattoos and the need for lumbar epidural analgesia remains controversial [137] . Forensic evidence — Adolescents' risk-taking behavior can sometimes predispose those with piercings into a situation where forensic evidence might need to be gathered [138] . Body piercing tracts or the grooves in jewelry may act as a reservoir for DNA from the victim or the perpetrator. The locations of piercings should always be documented since piercing hardware can leave patterned injuries or marks (abrasions, bruises) during a violent assault or rape. REMOVAL Piercing — Removal of body piercing simply involves removal of the jewelry, although the hole may remain open. However, the teen may be left with a scar from the jewelry site and may require surgical revision for cosmetic reasons. A consistent proportion of adolescents and young adults (13 to 18 percent) report removing their piercings voluntarily; the reasons they cite for removal include dissatisfaction, infection, and disinterest [12,15,27] . Many clinicians do not know how to remove jewelry from piercing sites, which can delay or interfere with care for the teenager who arrives in the emergency department as a result of trauma or who is unconscious and needs the jewelry removed because of swelling, infection, or radiologic procedures [139] . The three basic types of body jewelry are: Barbell studs — Two removable beads on either end of a straight or curved bar; used in the tongue, eyebrow, navel, nipple, clitoris, or glans penis (show picture 2) Labaret studs — Similar to the barbell except that it has a fixed disc on one end; used in tongue or lower lip with bead end exposed (show picture 3) Captive bead rings — Used for navel, nipple, and high ear piercings (show picture 4)

Piercings that involve the insertion of plastic and wood plugs (3-D inserts) or pocketing require skin incision for removal. Barbells and labarets are removed by holding the bar with forceps and using another pair to unscrew the bead [139] . Captive bead rings are removed by holding the ring on either side of the bead and releasing the tension on the bead. If the tissue around the jewelry is edematous, the best procedure is to compress the edematous tissue and remove the jewelry as described rather than trying to excise the jewelry. A body piercing jewelry removal kit that was designed by healthcare providers and a body artist is commercially available; it provides education and proper tools for removal [140] . Many adolescents and young adults may be reluctant to remove body jewelry because they are afraid the hole will close [27] . They may be more willing to remove the jewelry during elective surgical or diagnostic procedures if alternative means to keep the hole patent are suggested. These include replacing the jewelry with suture material, teflon posts (available at design studios), or a nonmetallic intravenous (IV) catheter. One technique for temporary removal of piercing jewelry is described below [141] : Disinfect the piercing and pierced area Open the piercing jewelry by removing the bead from the bar or ring Place the tip of a tightfitting IV catheter (14 or 16 gauge), without the needle, over the threaded tip of the bar Advance the IV catheter caudally, pushing the bar out of the skin tract Remove the jewelry, leaving the IV catheter in the subcutaneous skin as a spacer Reverse the steps of this procedure to replace the jewelry It is not known how long a piercing will remain open without jewelry if none of the above methods are used to keep it open. Several factors may contribute including the amount of stretching and movement of the site. Tattoos — Tattoo removal is more complicated and more expensive than is tattoo application. One method for hiding an undesirable tattoo is to cover it with another design. In the past, the most frequently used removal processes involved abrasive techniques that would remove the superficial epidermal layer and allow the pigment to leach out of the skin. Other methods included cryosurgery, thermal cautery, and surgical resection. More recently, tattoos are removed with laser therapy. All removal methods, including the laser, can leave visible scars [35,142] . Lasers employing different wavelengths can be used to remove different color tattoo pigments. The actual mechanism of ink removal is not well understood, but it is thought that the laser pulse fractures the tattoo pigment into small particles that are then taken up by local macrophages or scavenger cells or eliminated transepidermally [143,144] . Cases of regional lymphadenopathy following laser tattoo removal have been reported, raising additional questions about pigment safety [145] . Although laser removal is generally safe, skin hypo- or hyperpigmentation and hypersensitivity reactions (especially among people who experienced this reaction with the tattoo application) are potential complications [143,146,147] . Laser treatment of some tattoo pigments is associated with the creation of toxic and/or carcinogenic compounds [148,149] . Furthermore, laser treatment requires several sessions, can be costly, and is not covered under most insurance plans.

Technologic advances may facilitate safe and effective tattoo removal. One such advance is the development of a microencapsulated biodegradable and bioabsorbable ink (Freedom-2 ink, www.freedom2ink.com). The ink is contained in beads made of a synthetic polymer that is commonly used in surgical glue and artificial joints. Like other tattoo inks, it provides permanent skin marking. However, when exposed to laser energy the beads fall apart and the exposed pigment is resorbed by the body [150] . In animal studies, Freedom-2 tattoos were more effectively removed with laser treatment than India ink tattoos (52 versus 22 percent two weeks after laser treatment and 65 versus 27 percent nine weeks after treatment) [151] . The long-term safety of Freedom-2 ink has yet to be established [150] . RECOMMENDATIONS — Patients are more likely to discuss the issue of body art if the clinician does not speak or act judgmentally. Adolescents in particular are attuned to nonverbal cues. If these are dismissive, a teen may truncate discussions with his or her clinician and instead discuss body art with someone who provides him or her with inaccurate information. Teens often will seek advice from a commercial tattoo or piercing artist instead of discussing the issue with clinicians [11,20,38,152] . The role of the clinician is to provide patients with factual information to permit informed decision-making about either tattoo application or body piercing. The following guidelines may be used when counseling about either body piercing or tattooing [11,153] : Remind teens that most reputable studios require individuals to be 18 years old before a tattoo or piercing can be applied without parental permission. Many studios will not accept a note from the parent and require the parent to accompany his or her child to the studio. Encourage the patients to talk to others who have been tattooed or pierced. Remind patients they can take time to make these decisions and urge them not to make the decision under pressure, in haste, or while intoxicated. Patients should consider their choices of tattoo design and body site for tattooing or piercing carefully. Remind them people may have negative judgments about certain tattoo designs and locations or certain body piercing sites. Encourage placement on body parts where patients have control over who sees the tattoo or piercing [154] . Encourage patients to examine several studios before selecting one and to watch the artist place either a tattoo or piercing and to avoid commercial establishments in shopping malls. Remind patients of the health risks involved with amateur tattooing or piercing. Individuals should make sure the artist uses disposable gloves and disposable or adequately sterilized needles before each procedure. Also, the body site for either tattooing or piercing should be thoroughly cleaned with an antimicrobial solution. After-care instructions should be provided. Remind patients that no topical anesthetic is used for either tattooing or piercing. Patients should be aware of risks for infection, including hepatitis B or C, HIV, or local skin infections, even when good technique is used. Allergic reaction to either tattoo pigment or jewelry also may develop. Surgical stainless steel, 14K gold, niobium, and titanium are the best materials for jewelry to reduce the risk of a contact dermatitis. Patients should be aware that most tattoo and body piercing artists are unlicensed and most states do not require formal training. Furthermore, the artists are not required to obtain hepatitis B immunization in most states. Tattoo and

piercing studios are loosely regulated and the depth and quality of standards vary from state to state. Finally, tattoo pigments are not FDA approved for intradermal application. Remind patients about the costs involved for application of tattoos or body piercing. They also should be aware that tattoos are permanent and costly to remove. Friends, rather than family, of adolescents seem to influence decisions about body art [27] . Clinicians should provide targeted and repeated education to transmit the message of effective decision-making and evaluation of risks, particularly in adolescents with congenital heart disease [84] . Brochures, health education videos, and additional Web sites are available (show table 2). Clinicians should become knowledgeable about the regulations in their cities, counties, and states regarding body art. The National Environmental Health Association (NEHA) has created a professional advisory document for those wishing to develop regulations for the body art industry [155] . Several states already have used the NEHA code when implementing newly adopted body art regulations for their states.

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108:159. Ferguson, AW, Jollands, A, Kirkpatrick, M, et al. Infective endocarditis presenting with Parinaud's dorsal midbrain syndrome. J Pediatr Ophthalmol Strabismus 2006; 43:41. Dupont, P, Maragnes, P, de la, Gastine G, et al. [Tricuspid valve endocarditis after umbilical piercing]. Arch Mal Coeur Vaiss 2006; 99:629. Hoyer, A, Silberbach, M. Infective endocarditis. Pediatr Rev 2005; 26:394. Yoshinaga, M, Niwa, K, Niwa, A, et al. Risk factors for in-hospital mortality during infective endocarditis in patients with congenital heart disease. Am J Cardiol 2008; 101:114. Shebani, SO, Miles, HF, Simmons, P, et al. Awareness of the risk of endocarditis associated with tattooing and body piercing among patients with congenital heart disease and paediatric cardiologists in the United Kingdom. Arch Dis Child 2007; 92:1013. Armstrong, ML, DeBoer, S, Cetta, F. Infective endocarditis after body art: a review of the literature and concerns. J Adolesc Health 2008; . Armstrong, ML, DeBoer, S, Cetta, F. Infective endocarditis after body art: a review of the literature and concerns. J Adolesc Health 2008; 43:217. Goldrick, BA. Endocarditis associated with body piercing. Am J Nurs 2003; 103:26. Wilson, W, Taubert, KA, Gewitz, M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:1736. Cetta, F, Graham, LC, Lichtenberg, RC, Warnes, CA. Piercing and tattooing in patients with congenital heart disease: patient and physician perspectives. J Adolesc Health 1999; 24:160. Millar, BC, Moore, JE. Antibiotic prophylaxis, body piercing and infective endocarditis. J Antimicrob Chemother 2004; 53:123. Delahaye, F, Wong, J, Mills, PG. Infective endocarditis: a comparison of international guidelines. Heart 2007; 93:524. Niwa, K, Nakazawa, M, Miyatake, K, et al. Survey of prophylaxis and management of infective endocarditis in patients with congenital heart disease: Japanese nationwide survey. Circ J 2003; 67:585. Hayes, MO, Harkness, GA. Body piercing as a risk factor for viral hepatitis: An integrative research review. Am J Infect Control 2001; 29:271. Haley, RW, Fischer, RP. Commercial tattooing as a potentially important source of hepatitis C infection. Clinical epidemiology of 626 consecutive patients unaware of their hepatitis C serologic status. Medicine (Baltimore) 2001; 80:134. Tope, WD. State and territorial regulation of tattooing in the United States. J Am Acad Dermatol 1995; 32:791. Dron, P, Lafourcade, MP, Leprince, F, et al. Allergies associated with body piercing and tattoos: a report of the Allergy Vigilance Network. Allerg Immunol (Paris) 2007; 39:189. Timko, AL, Miller, CH, Johnson, FB, Ross, E. In vitro quantitative chemical analysis of tattoo pigments. Arch Dermatol 2001; 137:143. FDA CFSAN/Office of Cosmetics and Colors Tattoos and Permanent Makeup. (2006). Available at: www.cfsan.fda.gov/~dms/cos204.html (Accessed on May 20, 2008). Engel, E, Santarelli, F, Vasold, R, et al. Modern tattoos cause high concentrations of hazardous pigments in skin. Contact Dermatitis 2008; 58:228. Neri, I, Guareschi, E, Savoia, F, Patrizi, A. Childhood allergic contact dermatitis from henna tattoo. Pediatr Dermatol 2002; 19:503. Farrow, C. Hair dye and henna tattoo exposure. Emerg Nurse 2002; 10:19. Simpson-Dent, SL, Hunt, SH, Davison, SC, Wakelin, SH. Tattoo dermatitis from primary sensitization to clothing dyes. Contact Dermatitis 2001; 45:248. Jappe, U, Hausen, BM, Petzoldt, D. Erythema-multiforme-like eruption and depigmentation following allergic contact dermatitis from a paint-on henna tattoo, due to para-phenylenediamine contact hypersensitivity. Contact Dermatitis 2001; 45:249. Mohamed, M, Nixon, R. Severe allergic contact dermatitis induced by paraphenylenediamine in paint-on temporary 'tattoos'.

Australas J Dermatol 2000; 41:168. Zapolanski, T, Jacob, SE. Avoiding paraphenylenediamine exposure in children. Pediatr Ann 2008; 37:104. Jacob, SE, Zapolanski, T, Chayavichitsilp, P, et al. p-Phenylenediamine in black henna tattoos: a practice in need of policy in children. Arch Pediatr Adolesc Med 2008; 162:790. Saleeby, ER, Rubin, MG, Youshock, E, Kleinsmith, DM. Embedded foreign bodies presenting as earlobe keloids. J Dermatol Surg Oncol 1984; 10:902. Buchwald, C, Nielsen, LH, Rosborg, J. Keloids of the external ear. ORL J Otorhinolaryngol Relat Spec 1992; 54:108. Ng, KH, Siar, CH, Ganesapillai, T. Sarcoid-like foreign body reaction in body piercing: a report of two cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 84:28. Dickinson, JA. Sarcoidal reactions in tattoos. Arch Dermatol 1969; 100:315. Blobstein, SH, Weiss, HD, Myskowski, PL. Sarcoidal granulomas in tattoos. Cutis 1985; 36:423. Carbone, L, Myers, L. Scleroderma and body piercing. J Pediatr 2002; 140:241. Lane, JE, Waller, JL, Davis, LS. Relationship between age of ear piercing and keloid formation. Pediatrics 2005; 115:1312. Kluger, N, Thomas, L. The dragon with atypical mole syndrome. Arch Dermatol 2008; 144:948. McGeary, SP, Studen-Pavlovich, D, Ranalli, DN. Oral piercing in athletes: implications for general dentists. Gen Dent 2002; 50:168. Leichter, JW, Monteith, BD. Prevalence and risk of traumatic gingival recession following elective lip piercing. Dent Traumatol 2006; 22:7. Kapferer, I, Benesch, T, Gregoric, N, et al. Lip piercing: prevalence of associated gingival recession and contributing factors. A cross-sectional study. J Periodontal Res 2007; 42:177. Maibaum, WW, Margherita, VA. Tongue piercing: a concern for the dentist. Gen Dent 1997; 45:495. De Moor, RJ, De Witte, AM, De Bruyne, MA. Tongue piercing and associated oral and dental complications. Endod Dent Traumatol 2000; 16:232. Kretchmer, MC, Moriarty, JD. Metal piercing through the tongue and localized loss of attachment: a case report. J Periodontol 2001; 72:831. Er, N, Ozkavaf, A, Berberoglu, A, Yamalik, N. An unusual cause of gingival recession: oral piercing. J Periodontol 2000; 71:1767. Ram, D, Peretz, B. Tongue piercing and insertion of metal studs: three cases of dental and oral consequences. ASDC J Dent Child 2000; 67:326. Botchway, C, Kuc, I. Tongue piercing and associated tooth fracture. J Can Dent Assoc 1998; 64:803. Price, SS, Lewis, MW. Body piercing involving oral sites. J Am Dent Assoc 1997; 128:1017. Kopp, WK. Piercing. J Am Dent Assoc 1998; 129:16. Campbell, A, Moore, A, Williams, E, et al. Tongue piercing: impact of time and barbell stem length on lingual gingival recession and tooth chipping. J Periodontol 2002; 73:289. DeBoer, S, McNeil, M, Amundson, T. Body piercing and airway management: photo guide to tongue jewelry removal techniques. AANA J 2008; 76:19. Becker, PG, Turow, J. Earring aspiration and other jewelry hazards. Pediatrics 1986; 78:494. Schnirring, L. Exploring body art trends: Pierced tongues raise concern. Phys Sportsmed 2003; 31:7. Mandabach, MG, McCann, DA, Thompson, GE. Body art: another concern for the anesthesiologist [letter]. Anesthesiology 1998; 88:279. Slawik, S, Pearce, I, Pantelides, M. Body piercing: An unusual cause of priapism. BJU Int 1999; 84:377. Altman, JS, Manglani, KS. Recurrent condyloma acuminatum due to piercing of the penis. Cutis 1997; 60:237. Modest, GA, Fangman, JJ. Nipple piercing and hyperprolactinemia. N Engl J Med 2002; 347:1626. Hardee, PS, Mallya, LR, Hutchison, IL. Tongue piercing resulting in hypotensive collapse. Br Dent J 2000; 188:657. Schnirring, L. Body piercing and sports: An opening for trouble? Phys Sportsmed 1999; 27:27. Armstrong, ML, Elkins, L. Body art and MRI. Am J Nurs 2005; 105:65. Elster, AD, Link, KM, Carr, JJ. Patient screening prior to MR imaging: a practical approach synthesized from protocols at 15 U. S. medical centers. AJR Am J Roentgenol 1994; 162:195. Kuczkowski, KM. Lumbar tattoos and lumbar epidural analgesia: unresolved controversies. Can J Anesth 2008; 55:127. Kuchinski, A, Pereira, P, Armstrong, ML. Caring for

piercing clients: Attitudes, secondary trauma, and forensic evidence. Mosby's Nursing Consult, August 2006. Available at: www.nursingconsult.com (Accessed on May 20, 2008). Khanna, R, Kumar, SS, Raju, BS, Kumar, AV. Body piercing in the accident and emergency department. J Accid Emerg Med 1999; 16:418. Amundson, TB, Brown, JS, DeBoer, SL. Body piercing step-bystep guide for jewelry removal-health care professionals' handbook, 2006. Available at: www.medpierce.com (Accessed on August 22, 2007). Muensterer, OJ. Temporary removal of navel piercing jewelry for surgery and imaging studies. Pediatrics 2004; 114:e384. Anderson, R. Regarding tattoos: is that sunlight, or an oncoming train at the end of the tunnel?. Arch Dermatol 2001; 137:210. Kilmer, SL. Laser treatment of tattoos. Dermatol Clin 1997; 15:409. Ho, DD, London, R, Zimmerman, GB, Young, DA. Laser-tattoo removal--a study of the mechanism and the optimal treatment strategy via computer simulations. Lasers Surg Med 2002; 30:389. Izikson, L, Avram, M, Anderson, RR. Transient immunoreactivity after laser tattoo removal: Report of two cases. Lasers Surg Med 2008; 40:231. Ashinoff, R, Levine, VJ, Soter, NA. Allergic reactions to tattoo pigment after laser treatment. Dermatol Surg 1995; 21:291. Holzer, AM, Burgin, S, Levine, VJ. Adverse effects of Q-switched laser treatment of tattoos. Dermatol Surg 2008; 34:118. Cui, Y, Spann, AP, Couch, LH, et al. Photodecomposition of Pigment Yellow 74, a pigment used in tattoo inks. Photochem Photobiol 2004; 80:175. Vasold, R, Naarmann, N, Ulrich, H, et al. Tattoo pigments are cleaved by laser light-the chemical analysis in vitro provide evidence for hazardous compounds. Photochem Photobiol 2004; 80:185. Removable permanent tattoo ink. Med Lett Drugs Ther 2007; 49:75. Shawgo, RS, et al. In vivo evaluation of pigments engineered for removal. Lasers Surg Med Suppl 2006; 18:19. Armstrong, ML. A clinical look at body piercing. RN 1997; 61:26. Armstrong, M, McConnell, C. Promoting informed decision-making about tattooing for adolescents. J Sch Nurs 1994; 10:27. Armstrong, ML, Roberts, AE, Koch, JR, et al. Motivation for contemporary tattoo removal: A shift in identity. Arch Derm 2008; In press. Body Art: A comprehensive guidebook and model code. Published by NEHA; Denver, CO 1999. GRAPHICS Pocketing The ends of the piercing jewelry are embedded into the skin leaving the middle of the shank exposed, as depicted above. Genital piercing in males and females Site Healing time Comments Males Horizontal pin through the glans 8 to 10 weeks, up to 6 months Requires experienced piercer Very bloody and painful Severe bleeding and/or loss of erection may result if cavernosum is inadvertently pierced Foreskin must remain pulled back for adequate air circulation Vertical pin through the glans at least 2 months Requires experienced piercer

Rim of glans 4 to 6 weeks Requires professional piercer Worn by circumcised men Frenum/frenulum Easier to execute and less painful than other penis piercings Scrotum Raphe At least 6 to 8 weeks Sitting may be painful during healing Between testis and base of penis Short Requires experienced piercer Foreskin Short May cause considerable swelling, so no more than two piercings should be performed simultaneously Females Outer labia 4 to 10 weeks Considerable swelling for several days Inner labia Short if post-piercing instructions are followed Piercing hole vanishes quickly after removal of ring Clitoris 4 to 10 weeks The clitoral hood is more often pierced since clitoral piercing is difficult and painful Nipple 6 weeks to 6 months Breastfeeding is not normally constrained if milk ducti remain intact. Jewelry should be removed in the sixth month of pregnancy and can be reimplemented 3 months after weaning. Data from: Stirn, A. Body piercing: medical consequences and psychological motivations. Lancet 2003; 361:1205. Barbell stud Courtesy of R Michelle Schmidt, MD and Myrna L Armstrong, EdD, RN, FAAN. Labaret stud Courtesy of R Michelle Schmidt, MD and Myrna L Armstrong, EdD, RN, FAAN. Captive bead ring Courtesy of R Michelle Schmidt, MD and Myrna L Armstrong, EdD, RN, FAAN. Additional brochures, health education videos, and Web sites regarding body art 1. "Thinking about tattooing or body piercing" (715633A). For information: Attn: Corinna Wadleigh, Director, Educational Resources, Channing L. Bete Co., Inc. 1-800-628-7733 2. Tattoos: A guide for safety and body piercing: A guide to safety. Available from WR Spence, MD, Health EDCO, Waco, TX 76702-1207. 1-800-299-3366 or www.healthedco.com

3. Several brochures on tattoing and body art are available from ETR Associates. 1-800-2993366 or 1-800-435-8433 (fax) or www.etr.org 4. " A tattoo?...You." A health education video on tattooing. Texas Tech University Health Sciences Center School of Nursing, Room 2B164, 3601 4th St., Lubbock, TX 79430 or 806-7432002 (phone) or 806-743-1622 (fax) 5. www.tattoo.about.com