Piercings: body jewellery with risks

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Millions of people worldwide wear piercings. Percutaneous body jewellery is very popular, especially among teenagers and young adults, but it can lead to serious complications – increasingly an issue for doctors and health politicians.

Percutaneous body jewellery (piercing) has become a fashionable mass phenomenon that doctors have to deal with more and more often: Piercing jewellery can interfere with diagnostic imaging or interfere with medical procedures such as surgery. And of course, the jewellery itself can cause complications, which is why there is intensive discussion about medical and health aspects of damage caused by piercing, but also by tattoos or certain cosmetic operations.

Among the foundations of the discussion are efforts to determine the prevalence of tissue-damaging body jewellery and the associated complication rates. Only a few weeks ago, British public health researchers published a comprehensive study representative of Great Britain. There are also figures from Germany and – increasingly – publications on casuistics of complications.

In Great Britain, 10,503 citizens older than 16 years were asked whether they had ever had a piercing. Piercing is the process of attaching a piece of jewellery with a hollow needle after perforating tissue; piercing the earlobes is not generally considered piercing. According to the definition that excludes the earlobes, ten per cent of all Britons are or have been pierced, and 46.2 per cent in the 16-24 year old female group. Women are three times more likely to wear percutaneous body jewellery than men. The average number of piercings of all respondents was 1.7 – so many Britons have multiple piercings.

The same applies to Germany: piercings are no longer only worn by minorities, such as the punks in the 70s and 80s. Body jewellery is now widespread, especially among young people.

Women pierced more often

According to the survey, the prevalence of piercings is 6.5 per cent. This means that about 5.3 million Germans are pierced. Interviews were conducted with 1,000 East and West Germans aged 14 to 92 (n = 2,043). In the age group 14 to 24 years, 38 percent of the women and 16 percent of the men had a piercing, 41 percent of the women and 27 percent of the men of this age were tattooed and/or pierced.

Since the frequency and type of complications depend, among other things, on the location of the piercing, the choice of body region is interesting: Britons prefer the belly button (33 percent), followed by the nose (19 percent) and ear (13 percent). Nine percent each had the jewellery applied to the tongue and nippelpiercing, eyebrows (eight percent) and genitals (two percent).

In Germany, piercings seem to predominate in the head and neck area, especially on the ear. There is no comprehensive survey on the localisation of piercings in Germany comparable to the British study. In a study by the Zentralkrankenhaus Bremen, 2,000 colleagues working in private practices or clinics were asked to document piercings they had seen in the head and neck area of patients and to ask about other piercings and complications. There were 699 piercings documented in 273 individuals: 44.8 per cent were on the ear (excluding lobules), 22.8 on the nose (nostril, columella, septum), 15.3 per cent on the tongue, 9.8 per cent on the eyebrows, six per cent on the lip, and the remainder on the frenulum and chin. Additionally, other body sites pierced were the belly button (13.1 per cent), nipples (2.2 per cent) and genitals (0.8 per cent).

The complication rate for piercings essentially depends on

– the localisation

– the material used

– the experience of the piercer

– the hygienic conditions during the piercing and

– the aftercare.

The British researchers tried to quantify health problems related to piercing with the question: “Have you had swelling, bleeding, infections, allergies, lacerations or other injuries from piercing, or no health problems?”

– One of the problems occurred in 27.5 per cent of piercings, and in 31 per cent of 16-24 year olds.

– Professional help from pharmacists, doctors or piercers was needed for 13 per cent of all piercings (15 per cent among 16-24 year olds).

– One in 100 piercings among 16-24 year-olds led to hospitalisation.

In the Bremen study 28 percent of the pierced persons reported problems with the healing process, nine of them were hospitalised for this reason.

The main risks of piercings are bacterial and viral infections (up to necrosis), bleeding, tears, allergies, excessive scarring (keloids) and foreign body granulomas. The most common pathogens of bacterial infections are Staphylococcus aureus and S. epidermidis, type A and B streptococci, Pseudomonas species and mycobacteria. Contact lens infections can also be traced back to infection from piercing in many cases: The bacterial colonisation of the lens and the piercing piece are then identical. The viral infections observed include hepatitis and HIV.

According to the current British study (1), piercings are most prone to complications for the age group of 16 to 24 year-olds

– in the genital area (44.6 percent)

– on the nipples (24.7 per cent)

– on the tongue (24.3 per cent)

– on the belly button (14.8 per cent)

– the ear (14.4 per cent) and

– on the nose (8.9 per cent).

Injuries to nerves and larger blood vessels can occur on the male genitals (penis, scrotum), as well as ascending infections, which – as with piercings on the female genitals – can cause infertility. Urethra ruptures have been observed with penile piercings. They can also damage condoms.

A possible complication of piercings on the breast is obliteration of the mammary gland ducts with lactation disorders in women. Abscesses also occur, sometimes with massive lesions, which usually require systemic antibiotics and often surgery. Endocarditis has been described in isolated cases after nipple, nose, chin and navel piercing. In addition to antibiotics, heart valve surgery was necessary in individual cases.

According to the current British study, belly button piercings cause complications in 15 per cent; in previous studies, the frequency is given as up to 40 per cent. Doctors are particularly concerned to observe complications of belly button piercings such as phlegmon already in very young girls, i.e. ten to twelve year olds. Granulomas, partly inflammatory and weeping and not healed even weeks after removal of the jewellery, have been diagnosed.

Local infections are common with “high” ear piercings

Multiple and “high” piercings that perforate the cartilage are particularly prone to complications. The avascular cartilage predisposes to poor healing of the perforating space maintainer or the jewel with wound healing times of four months to one year and subsequently to local infections. In the auricle, the incidence of complications is 35 per cent.

“Local infections without purulent secretion are difficult to distinguish from allergic contact dermatitis in individual cases”, says a doctor. The allergic reaction, which can also manifest itself as a pigmentation disorder, should be treated with a corticosteroid-containing skin ointment, the uncomplicated local infection with a bactericidal ointment.

The risk of perichondritis or a subperichondral abscess is greatest within the first month after a piercing perforation, especially in the warm season. The most common pathogen is Pseudomonas aeruginosa. Apart from antibiotic therapy, surgical treatment is indicated. Permanent damage with partial necrosis of the ear cartilage and permanent deformations can occur. Traumatic auricular tears are mostly caused by sports and minor trauma when piercing is too close to the periphery.

In the case of nose piercing, for example in the area of the septum, the perforation of cartilage should also be avoided because of the danger of perichondritis and abscess formation. According to the doctor, the consequences of this can often only be treated by extensive plastic reconstruction of the nasal septum.

In the mouth area, the tongue is the most frequent localisation. It is usually perforated in the midline and directly in front of the attachment of the frenulum. Injuries to branches of the lingual artery can lead to severe bleeding and haematoma formation and even obstruction of the upper airways. If there is massive swelling of the tongue, intubation or tracheotomy should be considered. In emergency situations like these, the piercing jewellery must be removed immediately, as is usually the case with less dangerous complications or when surgery is planned. Removal is also desirable in minimally invasive procedures.

Doctors should also familiarise themselves with the three main types of closure mechanisms; in an emergency, the jewellery can be destroyed. If the doctor removes it, written consent should be obtained if possible. The jewellery should remain outside the body as long as the wound is not closed.

Some women put their navel piercing back in immediately after waking up from the anaesthesia of a laparoscopic intervention, against medical advice. The increased risk of infection must be explicitly pointed out. Also, patients often let weeks to months pass before they consult a doctor in case of problems because they absolutely want to keep the piercing. However, it is important to avoid condemnation or discrimination of pierced patients.

Those at significantly increased risk of complications include patients with diabetes mellitus or with an impaired immune system for other reasons (for example, after organ transplantation, with glucocorticoid therapy or HIV infection), people with heart defects, bleeding tendencies, atopic dermatitis or sarcoidosis (granuloma formation). In any case, the costs of treating complications can be considerable: they range from 3 000 to 4 300 euros for treatments after nipple abscesses.

Piercing has so far been an unlicensed trade. There is no recognised training, a large proportion of piercers learn by watching and with the help of instructional videos. Doctors been campaigning for years, also in the interests of consumer protection, for piercing to become a recognised profession with standardised training and for clear and specific standards for certification, quality assurance and supervision of piercing studios to be developed in agreement with the authorities. So far, this has not been implemented in any European country.

Many health authorities feel that they are not adequately staffed to effectively monitor studios anyway. An enquiry at the health department of a large city revealed that on average, only those piercing studios known to the department can be visited once every five years. But that is only a fraction.