An 18-year-old female came to clinic because of a problem with a navel ring. She had the piercing placed 2 months previously and had been doing appropriate care. About 1 week ago, the jewelry caught on clothing and caused a small tear and bleeding. The initial redness and swelling had not subsided, and she now noticed that the redness was spreading and there was increased tenderness. She noted that the initial clearish fluid was now thicker and yellow. She denied previous problems with her piercing, sharing jewelry, or other trauma. The review of systems showed no fever, chills, myalgia or other wounds.
The pertinent physical exam showed a healthy appearing female with normal vital signs.
Her navel was pierced at the 12 o’clock position with a ring and ball-type jewelry piece. She had erythema, ~1.5 cm extending in a fan-shaped pattern from 9 to 3 o’clock around the piercing, with a small amount of yellow fluid able to be expressed from around the jewelry. She had moderate tenderness over the jewelry and erythematous skin. The rest of her examination was normal. The diagnosis of localized cellulitis was made. The area was cleaned and some of the drainage was sent for gram stain and culture. She was instructed to keep the jewelry in place, use isotonic saline soaks (gauze pads saturated) several times a day, and clean warm compresses several times/day. She was also started on cephalexin and told to return if she had increasing wound symptoms, or new abdominal pain or fever over the night. By the next day, the erythema had decreased to around a 1 cm fan-shaped area and she had decreased tenderness. The gram-stain showed gram-positive cocci in clusters but was too early for identification. She was instructed to continue the current regimen and finish all of the antibiotics. She was also instructed to continue her after-care regimen until the piercing fully healed over the next several months.
Body piercing is the intentional perforation of a body tissue and insertion of an ornament that is for decorative, cultural, spiritual, or other reasons. It is one form of body art which also includes tattooing. Body art has been used over centuries of time across the globe.
It is estimated that body piercing prevalence is 30-50% in the 18-25 year old US population. It is popular among all ages, social classes and occupations. It does vary with certain ethnic classes and females are more common than males to have a body piercing. Basically almost any area can be pierced including the genitals and eye globe itself.
There is a high rate of complications (20-35%) which most are relatively self-limited.
Risks of body piercing include:
- Local – bleeding, infection, skin irritation, mechanical tissue tearing, hypersensitivity to the metal, granuloma, scarring, embedded jewelry, edema and ischemia, and dental problems
- Systemic – endocarditis, sepsis, brain abscess, upper-airway compromise, viral infections (e.g. Hepatitis B, Hepatitis C, HIV)
Group A beta-hemolytic Streptococcus, Staphylococcus (methicillin sensitive and resistant) and Pseudomonas are the most common bacterial infections. Body piercing has been associated with increased risk-taking in adolescents including substance abuse, sexual risk taking, and violence and suicide.
The United States and other countries regulate body piercing, but many people will self-pierce or use non-licensed practitioners. A listing of legal standards for minors in the US can be found here. Listings of local licensed practitioners may be available though local health departments who oversee the industry. At least one professional association is available in the United States, the Association of Professional Piercers. Like other professional organizations, membership is voluntary, but criteria standards are set for initial and continuing membership along with opportunities for continuing professional development and education of the lay public.
Healing time depends on several factors including the individual, piercing location, type of jewelry and aftercare of the piercing. Cartilage takes longer to heal than skin itself (ear lobe healing is around 6-8 weeks versus pinna piercing which may take 3-8 months). Areas that are covered or easily irritated such as navel, genitals and nipples also take longer. In general, ear lobes and tongues heal around 6-8 weeks, face around 3 months, and navel and cartilage heal in 3-8 months. Fastidious aftercare is necessary to decrease the potential side effects and needs to be continued much longer than most individuals believe. Even a healed piercing needs aftercare for up to a year so the skin epithelizes well. Jewelry with niobium, titanium, surgical steel, gold and plastic polymers are recommended for initial piercings. There are industry standards for materials used for different types of jewelry and its components.
After care includes washing hands prior to touching the piercing, soaking with saline for 5-10 minutes 1-2x/day, washing with a small amount of mild soap daily and rinsing thoroughly. Drying the area with disposable paper products is recommended as even clean cloth items such as towels could harbor bacteria or cause mechanical irritation. Alcohol, Hibiclens®, and Betadine® are not recommended because they may cause more skin irritation. When there is a local infection it is usually best to try to leave the jewelry in place (removing can cause abscess formation) which allows for improved drainage and epidermal healing. After 5-7 days if it is not healing then the patient probably needs to have the jewelry removed along with possible surgical drainage and IV antibiotics.
Questions for Further Discussion
1. At what age is a minor too young for a body piercing?
2. How would you counsel someone considering a body piercing to look for in a reputable piercer?
3. What are signs of contact dermatitis or metal hypersensitivity with piercings?
4. What are the risks associated with tattooing?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Piercing and Tattoos
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Carroll ST, Riffenburgh RH, Roberts TA, Myhre EB. Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Pediatrics. 2002 Jun;109(6):1021-7.
Armstrong ML, Koch JR, Saunders JC, Roberts AE, Owen DC. The hole picture: risks, decision making, purpose, regulations, and the future of body piercing. Clin Dermatol. 2007 Jul-Aug;25(4):398-406.
Hogan L, Armstrong ML. Body piercing: more than skin deep. Skin Therapy Lett. 2009 Sep;14(7):4-7.
Miller JM, Fitzpatrick JJ. Piercing: does health education make a difference? Nurse Pract. 2010 Jun;35(6):48-52.
Fijalkowska M, Pisera P, Kasielska A, Antoszewski B. Should we say NO to body piercing in children? Complications after ear piercing in children. Int J Dermatol. 2011 Apr;50(4):467-9.
Body Aftercare Instructions. Association of Professional Piercers. Available from the Internet at http://www.safepiercing.org/publications/brochures/body-aftercare/ (cited3/23/2012).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Practice Based Learning and Improvement
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital