Faced with a mostly unregulated industry of tattooists and piercers, clinicians need to be on the lookout for infections and other complications.

Though their popularity has skyrocketed over the past two decades, tattoos, piercings, and other forms of body modification date back thousands of years. A recent study found that 20% of college students had one or more tattoos and/or piercings of body parts other than the earlobes.1 Another report shows 3%-5% of the adult population sports tattoos.2 Clinicians should be aware that adolescent patients with body art are more likely to engage in other risk-taking behaviors, such as drug use and unprotected sexual activity.3

Types of body art

Tattooing is the indelible marking of the body using needles to insert small amounts of pigment directly into the skin. While a professional artist using appropriate needles and dyes can create a well-designed work of art, many tattoos are done by nonprofessionals using sewing needles, straight pins, paper clips, pens, or pencils. The dye may be charcoal, soot, mascara, or carbon. These tattoos are usually black and uneven. Piercing can be done on almost any part of the body, but the ear remains the most popular site. Other common areas are the eyebrow, nasal septum, nasal ala, tongue, nipples, navel, and genitals.

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Women may have their clitoris or inner or outer labia pierced. Male genitalia piercing sites include the head of the penis, the underside of the penile shaft, and the anterior or posterior areas of the scrotal sac.

Branding, the most controversial and riskiest form of body modification, involves a process in which the skin is burned severely to create a decorative scar. This extremely painful process can cause third-degree burns as well as damage to internal organs beneath the branded area.


There are very few local or federal regulations on the body-art industry. For the most part, tattoo artists and piercers are unlicensed personnel who learn their trade through an informal apprenticeship. Most have received no training in anatomy, infection control, or universal precautions. The Association of Professional Piercers (APP), which is devoted to self-regulation, recommends at least one year of apprenticeship for its members. An apprenticeship includes a course in bloodborne pathogens and instruction in sterilization, disinfection, and avoidance of cross-contamination. According to the APP Web site, 18 states have pending legislation to regulate body piercing, and a few states already have regulations on the books (www.safepiercing.org. Accessed January 10, 2007). There is a similar organization for tattooists, the Alliance of Professional Tattooists (APT).


Infection is the greatest risk associated with body modification. There have been reports of hepatitis B and C, as well as infections with such bacteria as Pseudomonas and staphylococci, including methicillin-resistant Staphylococcus aureus, tetanus, and TB. Individuals with artificial heart valves, prostheses, and medical conditions requiring antibiotic prophylaxis for dental procedures are particularly at risk. Diabetic patients on corticosteroids are also more susceptible to infection from piercings.

If hepatitis is suspected, order a complete blood count, total and direct bilirubin, prothrombin time, liver enzymes, and urinalysis, and plan referral to a specialist. If you suspect HIV, order an enzyme-linked immunosorbent assay screening test. If this test is positive, confirm with a Western blot. When a wound is present, obtain a Gram’s stain and culture and sensitivity.

Cellulitis in adults and children younger than 2 years may be treated with oral antibiotics for 10-14 days. Therapies include dicloxacillin (children 50 mg/kg/day, divided into four doses; adults 500 mg four times daily), cephalexin (children 50-75 mg/kg/day, divided into two doses; adults 500 mg b.i.d.), amoxicillin/clavulanic acid (children 45 mg/kg/day divided into two doses; adults 500 mg t.i.d.), or azithromicin (children 10 mg/kg/day daily for five days; adults 500 mg on day one, then 250 mg on days two through five). Culture and sensitivity should guide the selection of antibiotics.

The ear is the site of most piercing-related infections. Piercing the cartilage of the pinna has recently become more popular. The avascular nature of auricular cartilage results in poor healing and more serious infection. Auricular perichondritis can be distinguished from more superficial skin infections by palpating the cartilage (deeper infection causes acute tenderness).

Fluoroquinolones, such as ciprofloxacin, are recommended for auricular perichondritis because of their effectiveness against Pseudomonas. If the infection progresses to abscess, surgical incision and drainage may be indicated, but the result is often cosmetically undesirable.4 Superficial skin infections usually respond well to warm compresses and topical antibiotics, such as 2% mupirocin ointment. Oral antibiotics may also be necessary. Granulomas sometimes form around the site of a piercing or a tattoo and may resolve spontaneously. These frequently respond to intralesional or systemic corticosteroids, but surgical excision may be required.

Allergic reaction

An allergic reaction to the metal in the jewelry is a common complication of body piercing. In the event of such a reaction, the jewelry should be removed immediately. Ornaments made of nickel may be replaceable with others made from titanium or niobium, which are less allergenic. Follow protocol for anaphylaxis if there is an acute reaction, and refer to an emergency department when stabilized. A mild allergic reaction can be treated with topical corticosteroids. Allergic reactions to the dyes used in tattoos are also common (especially reds and yellows) and can occur years after the tattoo was created. Increased photosensitivity in inked areas may also be noticed.

Bacterial endocarditis

At least two cases of bacterial endocarditis have been traced to tongue jewelry, with patients presenting one to two months after the piercing was done.5,6 Neisseria mucosa and Hemophilus aphrophilus were the implicated organisms. The N. mucosa infection was treated with ceftriaxone 1 g t.i.d. and ciprofloxacin 200 mg b.i.d. The H. aprophilus infection was treated with triple antibiotics (ampicillin, nafcillin, and gentamicin). Given the propensity of mouth bacteria to settle on the heart valves, a high index of suspicion should be maintained for any patient with oral jewelry who presents with signs and symptoms of systemic infection. Even after the site has healed, the area around the jewelry may be colonized with bacteria that can find its way to the heart. Another case of infective endocarditis was caused by an infected nasal ala piercing.7 Despite the use of flucloxacillin, cefotaxime, and metronidazole, S. aureus continued to grow. Treatment was changed to flucloxacillin and vancomycin, and when the patient developed an allergic rash to flucloxacillin, vancomycin alone was used for the final three weeks of her six-week treatment.

Additional complications

Other sequelae of oral piercings include increased salivary flow, gingival injury or recession, and interference with speech. Tongue splitting, in which the anterior portion of the tongue is divided into two pieces to create a forked appearance, provides an increased surface from which bacteria can be introduced into the bloodstream. Ludwig’s angina is also seen in patients with oral piercings. This features a rapidly spreading cellulitis involving the submandibular, sublingual, and submental fascial spaces. Treatment includes broad-spectrum IV antibiotics and maintenance of the airway, possibly requiring intubation or tracheotomy.

Surgical drainage of abscesses is sometimes required. Finally, tongue jewelry is often implicated in broken and cracked teeth, and the American Dental Association has advised against oral piercings (www.ada.org/prof/resources/positions/statements/piercing.asp. Accessed January 10, 2007).

Keloid formation

Keloid formation is a complication that is usually associated with ear piercings but is sometimes seen in tattoos and other piercing sites. Removal of keloid tissue often results in further overgrowth of scar tissue. Intralesional corticosteroids have been found to be somewhat successful, as has intralesional verapamil. Because of the vascular nature of the tongue, piercings often cause prolonged bleeding. An even greater risk of tongue piercing is edema, which may cause airway obstruction. Airways can also be obstructed by aspirated jewelry from the mouth or nose.

Complications with jewelry

Jewelry can become embedded in tissue, most often as the result of ear piercing with a spring-loaded gun.8 It may be necessary to surgically remove the embedded earring by making a small incision under local anesthesia (without epinephrine). The patient should wait six to eight weeks after the swelling and tenderness have resolved before having the ear pierced again (longer earring posts should be used to avoid repeating the problem).

Snagged or pulled jewelry can lead to trauma. Earlobe laceration is the most common of this type of injury. Lacerations can be sutured under local anesthesia. If the tear is in the ear cartilage, many family practitioners refer to a specialist, since these injuries can be complicated by the avascularity of the cartilage. Heavy ear jewelry can cause an elongated tract or bifid deformity of the earlobe.

Jewelry placed superficially has a tendency to migrate to the skin surface, particularly in the case of navel rings. This is especially problematic in overweight or pregnant patients. Migration and rejection is more likely with thin-gauge jewelry that is heavily weighted.

Concerns for pregnant womenThere are special complications in pregnant women and nursing mothers. Because changes in body shape and size may alter the fit of jewelry and the hole size, new piercings are contraindicated during pregnancy. Navel rings should be removed whenever discomfort presents (flexible plastic space holders can be used to maintain the hole). Nipple piercings may cause mastitis, galactorrhea, and damaged milk ducts.

The jewelry itself can obstruct breastfeeding. Genital piercings increase the risk of severe lacerations during labor and delivery.

Genital piercings

Genital piercings have a unique set of complications. Keloid formation has been seen in clitoral piercings. Paraphimosis and priapism are reported in penile piercings. Paraphimosis requires a nerve block before reduction. Hyaluronidase can be injected into the prepuce to allow edematous fluid to dissipate. Priapism requires referral to an emergency department. A patient with a penile piercing suffered a ventral split of the urethra following an avulsion of the ring.

Urethral tears should be evaluated by retrograde urethrography. Introduction of a catheter may convert the tear to a complete transection. Partial tears may require a suprapubic cystotomy and primary repair. Patients should also be reminded of the potential compromise of barrier contraception and STD prevention from tears made by genital jewelry.

Branding burns

With regard to burns caused by branding, patients may need to be referred to a wound-care center. If the burns are mild, use cool compresses and topical dexamethasone aerosol spray every three hours. Patients may use acetaminophen or a nonsteroidal anti-inflammatory drug for pain control. Make sure the patient’s tetanus immunization is up to date.

Patient education

Tell patients to select a reputable person with a clean shop to perform the procedure. Recommend that they work only with APP-certified piercers and tattoo artists who belong to the APT. The client should make sure that the artist removes sterile tools from packaging and opens new disposable bottles of ink before each procedure. Brandings should be highly discouraged due to the potential for multiple complications.

New piercings should be cleaned one to two times daily with antibacterial soap and patted dry with disposable tissues or gauze. Jewelry should be moved back and forth during daily cleaning to prevent the metal from adhering to the skin and to remove debris from the canal. New tattoos should be covered with a sterile nonstick dressing until a scab forms. Clients must be alert to early signs of infection (e.g., erythema, edema, tenderness, yellowish discharge, foul smell, fever) and seek medical care if the site becomes infected. Some sites can take months to heal completely, so encourage patience.

Ms. Leman is a primary-care clinician with Heartland Community Health Clinic in Peoria, Ill. Ms. Plattner is a primary-care clinician with Laredo Medical Center in Zapata, Tex.


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2. Montgomery DF, Parks D. Tattoos: counseling the adolescent. J Pediatr Health Care. 2001;15:14-19.

3. Carroll ST, Riffenburgh RH, Roberts TA, Myhre EB. Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Pediatrics. 2002;109:1021-1027.

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5. Akhondi H, Rahimi AR. Haemophilus aphrophilus endocarditis after tongue piercing. Emerg Infect Dis. 2002;8:850-851.

6. Tronel H, Chaudemanche H, Pechier N, et al. Endocarditis due to Neisseria mucosa after tongue piercing. Clin Microbiol Infect. 2001;7:275-276.

7. Ramage IJ, Wilson N, Thomson RB. Fashion victim: infective endocarditis after nasal piercing. Arch Dis Child. 1997;77:187.

8. Koenig LM, Carnes M. Body piercing medical concerns with cutting-edge fashion. J Gen Intern Med. 1999;14:379-385.