Body piercing

What is body piercing?

Body piercing is the practice of creating an opening through a part of the human body to allow for adornment with jewels, metals or cultural pieces either for temporary or permanent use.

Like tattooing, body piercing is a form of body modification. Related body piercing techniques include [1]:

• Gauging or stretching: this is where larger diameter adornments are threaded through a piercing site every 4–6 weeks during healing to expand the hole created. A cultural variation of this is lip stretching to encompass large discs. Heavy adornments will also stretch the skin significantly over time.
• Pocketing: in this technique, the ends of a semicircular adornment are embedded into the skin, leaving the middle of the object exposed.
• Microdermal or transdermal piercing: in this technique, an anchor is embedded under the skin. It has small holes through which tissue grows during healing. Jewellery is screwed into the anchor. This technique is sometimes called anchoring.

Earrings 

Belly button jewelry 

Tongue stud 

Who undergoes body piercing?

Body piercing is observed across diverse cultures and has been practised for thousands of years. In Western populations, its prevalence wavers dramatically. Its popularity is determined by the reasons people decided to have a piercing; for example, to feel unique, for aesthetic reasons, eroticism, or conformity, or as a form of rebellion or self-control.

The incidence of body piercing is greatest in young adults and in women. It is correlated with increased risk-taking behaviour and a search for identity [2,3], but not with psychopathology or low self-esteem [4]. Multiple piercings (> 4) and/or intimate piercings, such as of the nipples or genitalia, increases the risk of concurrent high-risk behaviours and emotional distress [5].

Traditional forms and uses of body piercing continue to be practised world-wide, including in religious customs and cultural ceremonies incorporating spiritual beliefs and/or culture-specific symbolism. Traditional therapeutic uses of piercing include scarification and acupuncture-like piercing; for example, left nasal piercing in Ayurvedic medicine is thought to reduce the pain of menstruation and childbirth. Conversely, piercings placed in specific points have been blamed for ill health and infertility.

Maori and Pacific peoples may use bone or other traditional materials for cultural piercing [6]. Piercing techniques, adornments and possible complications from traditional piercing vary considerably. Fundamental in all cases is the importance of infection control measures and, where necessary, respectful, culturally-competent medical management.

Body piercing is also performed surgically to insert a magnetic tongue barbell in individuals with tetraplegia to help with the use of tongue-operated assistive technology [7].

What are the contraindications to body piercing?

Materials known to cause allergy — including anaphylaxis — must be avoided in the individuals undergoing body piercing, including any sanitary products normally used in the procedure (eg, nickel plated items, latex surgical gloves).

Strong contraindications

Body piercing is strongly contraindicated in individuals with local infection or inflammatory disease, including:

• Previous hypersensitivity reaction to any associated materials.
• Dental caries or gum disease — for oral piercings
• Eczema and psoriasis
• Sexually transmitted infection

Moderate contraindications

Body piercing is moderately contraindicated in individuals with the following conditions or circumstances:

• A family or personal history of keloid scarring, especially if over 11 years of age
• Valvular heart disease — for oral piercings
• Immunocompromise [8]
• Uncontrolled diabetes mellitus [9]
• Uncontrolled bleeding disorder
• Pregnancy — for abdominal and genital piercings as pregnancy may lead to implant rejection [10], tearing and scarring
• Breastfeeding — for nipple piercings; existing piercings may also cause problems [11]
• A lack of immunisation to hepatitis B
• A need for orthodontic treatment — due to the increased risk of nickel hypersensitivity reaction [12]
• Anaemia, smoking and/or poor nutrition — these may slow wound healing.

Body piercing regulations

Body piercing is widely considered a simple procedure, with potential complications being under-recognised by both providers and their clients [6,13,14]. Commercial body piercing (not including regular ear piercing) is typically done at tattoo studios and non-commercial piercing ‘backyard jobs’ are not uncommon [6,14].

The setting and regulation of industry standards for body piercing, under the overarching domain of public health, is the responsibility of the relevant territorial authorities. The New Zealand Ministry of Health provides Guidelines for the safe piercing of skin [6], which may form the basis of any local standards or serve as a resource for providers and their customers where there are no local governing standards.

In New Zealand, few regulatory standards are described or enforced. Most councils have age restrictions on carrying out body piercing, with interested individuals needing to be either 16 or 18 years of age at minimum. Adolescents may undergo body piercing prior to this age when providers are given written parental consent. With the exception of ear piercing where infants and children (usually girls) may have their ears pierced with parental consent, further body piercing in this age group is not regulated and has not been reported.

Intoxication and peer pressure may independently affect an individual’s decision to undertake the procedure. Individuals interested in undergoing body piercing should educate themselves on the topic and assess the risks; visiting multiple providers (to review sanitation, ask questions and check out reviews) is strongly recommended.

The body piercing procedure

Pre-procedure

• The client’s medical history should be recorded prior to the procedure so that any needed changes can be made accordingly (eg, ensuring a latex-free environment for the procedure, the client undergoing hepatitis B immunisation, antimicrobial prophylaxis being provided).
• After explaining the procedure, written, informed consent is obtained from the client.
• The environment in which the procedure will take place is prepared.
• The equipment needed for the procedure is prepared.
  • This equipment should include adequate sterile supplies for the procedure and any early complications (eg, bleeding).
  • Quality disposable/single-use equipment is recommended. This should be opened immediately prior to use and disposed of in sharps or biological hazards containers.
  • Special care should be taken with cleansing solutions and fluids to avoid contamination, as these are often reused and may transmit infection.
  • Expiry dates on all equipment should be adhered too.

Procedure

1. The client’s skin should be clean and free of infection or inflammation. Shaving the skin to remove body hair may be necessary.
2. The client’s skin is disinfected. Povidone–iodine is used around the eyes; elsewhere solutions of alcohol, alcohol plus chlorhexidine, alcohol or aqueous detergent plus povidone–iodine are recommended by the New Zealand Ministry of Health’s Guidelines for the safe piercing of skin [6].
3. The particular body piercing technique is performed.
   • Piercers may use a 12–16 gauge, hollow-bore needle to pierce the skin, guide jewellery through the needle with string or wire, and then withdraw the needle [1].
   • Simple piercings may be performed with a spring-loaded gun. Piercing guns are often the preference of non-specialised body piercing providers. These piercing guns are unable to be fully sterilised and are not recommended as they may increase trauma and complications such as infection.
4. A clean waterproof wound dressing is applied over the piercing.

Aftercare

Once the procedure has been performed, the pierced individual should avoid public swimming pools and spas due to the risk of infection. Contact with the piercing site should be avoided aside from cleaning. Cleaning should be once to twice daily with antimicrobial soap and water. Oral piercings should be cleaned with antiseptic, alcohol-free mouthwash. Ice may be used to reduce swelling. Intimate piercings and alternative piercing types require special care.

Healing times vary and are affected by the location of the piercing, individual client factors and aftercare. Any pus, ongoing bleeding, or other concerns should be reviewed by a medical professional.

What are the side effects and risks of body piercing?

The lack of regulation and incident reporting (especially regarding sensitive or high-risk piercings), means that estimates of the incidence of adverse effects of body piercing are inconsistent and unreliable [14].

Immediate complications of the body piercing procedure may include:

• Bleeding — the bleeding after the piercing can take from minutes (earlobe) to days (genitals) to stop
• Pain — as piercing is rarely undertaken with local anaesthetic
• Nausea — the pain experienced may lead to nausea.

Cutaneous adverse effects

The following cutaneous adverse effects may occur.

Contact dermatitis

• Allergic contact dermatitis is the most frequent non-infectious cutaneous complication.
• Nickel is the most common allergen [1,14].
• Multiple piercings increase the risk of contact dermatitis.
• Nickel-containing orthodontic treatment (prior to the piercing) decreases the risk [12].
• The use of hypoallergenic metalware (eg, surgical stainless steel, niobium, titanium or gold) is recommended, particularly in the period from the piercing to the resolution of healing [1,14].
• Irritant contact dermatitis can occur from the cleaning solutions used.
• Treatment involves the removal of the adornment or cleaning solution and its future avoidance.

Keloid and hypertrophic scars

• There is an increased likelihood of keloid and hypertrophic scarring if there are post-procedure complications (such as haematoma, infection, and excess skin tension) and/or delayed wound healing.
• Individuals over 11 years of age with a family history or personal history of keloid or hypertrophic scarring are at highest risk [1,15].
• Hypertrophic scars generally occur 4–8 weeks after the injury, increase in size for up to 6 months, then flatten over a period of a few years [15].
• Keloid scars may develop up to several years after the body piercing procedure and can continue to grow in size beyond the size of the original wound until the client’s late adulthood. Keloid scars mostly commonly occur during adolescence [15].
• Such scarring may be reduced with prophylactic silicone gel sheeting or intralesional corticosteroid injection [14,15].

Granuloma

• Once recognised, foreign body granuloma, a chronic inflammatory condition, can be treated with intralesional corticosteroid injection.

Contact dermatitis to disinfectant 

Blue discolouration of piercing scar 

Keloid scar at site of ear piercing 

Infectious complications

The penetration of the skin barrier with body piercing exposes underlying tissues. With body piercing, wound healing is slow due to the presence of a foreign body (the piercing jewellery), and in cartilaginous piercings, poor blood supply. The risk of infectious complications is greater in deep piercings and those through mucosal surfaces. Oral infections can also swell and occlude the body piercing client’s airway.

The list of potential infectious complications includes:

• Abscess
• Cellulitis
• Chondritis
• Sepsis
• Brain abscess — from oral piercing
• Infective endocarditis — from oral piercing
• Toxic shock syndrome — from genital piercing.

The most frequently isolated pathogens are Pseudomonas aeruginosa and Staphylococcus aureus. Potential viral infections include hepatitis B, hepatitis C and human immunodeficiency virus (HIV). As a precaution, body piercing clients should not donate blood for 6 months after piercing procedures.

Psychological effects

Body piercing can have psychological effects on individuals who undergo the procedure.

• Where it is necessary to remove piercings, it may be psychologically traumatic, especially when the piercings were attained for such reasons as identity, resilience, spirituality or remembrance. Using suture material, non-stick posts or non-metal catheters to maintain the body piercing opening [1,16] if the removal is intended to be temporary may provide the individual with some reassurance.
• The deformity that can occur with piercings can reduce self-esteem and body confidence.
• The individual’s disinterest leads to the intentional removal of 13–18% of body piercings at body sites other than the earlobes in Western culture [1].
• Individuals who undergo body piercing procedures may face discrimination and stigma arising from incorrect assumptions about the piercing, differing personal opinions, or non-conformance to staff dress codes and expectations around appearances.

Trauma

• Local structures may be damaged during body piercing.
• Oral piercings can cause gingival recession, the chipping of teeth, or the fracturing of dentures. They may also increase salivation, interfere with eating, and cause speech impediments [1,17].
• Nipple and genital piercings can cause trauma during breastfeeding and intercourse respectively [11].
• Physical force may dislodge a piercing and result in tearing, bleeding, swelling and/or pain as common complications. Dislodged oral or nasal piercings may lead to the adornment being swallowed or inhaled into the lungs [17,18].
• Damage to tissues may cause physical deformity. Genital piercings may alter urinary blood flow or cause priapism in men, and scarring, especially post-infection, is unsightly. Scarring in the genital area can cause infertility in rare cases [17].

Complications during investigations and surgery

• Piercings may obscure imaging during an X-ray or computed tomography scan.
• Depending on the metal composition, some piercings may be moved or pulled out by magnetic force during magnetic resonance imaging. Any piercing able to conduct electricity must be removed for surgery, as electrical burns can occur with electrocauterisation [16].
• Oral or nasal piercings, or secondary swelling, may obstruct intubation during an general anaesthetic. Dislodged piercings may be swallowed, embedded or inhaled into the lungs [17,18].
• Surgical risks include tearing, infection and damage to the piercing site, or complications due to a resulting physical deformity (eg, the placement of urinary catheter where urinary outflow has been altered due to the presence of a piercing) [17].
• Doctors and nurses are not routinely trained in the safe management of body piercings, nor is it necessarily intuitive [17,18].