Body piercing in adolescents and young adults

INTRODUCTION — The epidemiology and health hazards associated with body piercing will be reviewed here. Tattooing and issues related to body piercing in pregnancy are discussed separately. (See "Tattooing in adolescents and young adults" and "Maternal adaptations to pregnancy: Skin and related structures", section on 'Tattoos and piercing'.)

For the purposes of this topic, "body piercing" generally refers to piercing at sites other than the ear lobe. However, some sections discuss piercing of the ear lobe as well as piercing at other sites (eg, the sections on piercing procedure and health risks).

EPIDEMIOLOGY — Body piercing is increasingly common among adolescents and young adults [1-6]. Surveys of adolescents and young adults (13 to 29 years of age) suggest that 25 to 35 percent have a body piercing at a site other than the ear lobe [2,3,7,8].

A consistent proportion of adolescents and young adults (13 to 18 percent) report long-term removal of their jewelry (though the piercing tract may remain patent); the reasons that they cite for removal include dissatisfaction, infection, and disinterest [1,3,9].

Surveys evaluating the association between body piercing and high-risk behaviors (eg, tobacco use, drug use, sexual activity) in adolescents and young adults have inconsistent results [10-15]. Some suggest that the rate of high-risk behaviors is increased in those with multiple piercings or intimate (ie, nipple, genital) piercings [13,14].

COUNSELING PATIENTS ABOUT PIERCING — Clinicians and school nurses may be the first and perhaps the only source of credible information about body piercing for children and adolescents [16]. Adolescent and young adult patients are more likely to discuss body art if the clinician is not judgmental. If patients perceive negative judgment from the clinician, they may seek information from other sources (eg, friends, commercial piercing artists) [17,18].

●Proactive counseling – Proactive counseling can begin as early as first grade [16,19]. Such counseling does not address piercing directly, but highlights internal empowerment and self-esteem, which can bolster self-worth, decision making, and confidence, which in turn may affect motivation to obtain body piercing. Similarly, for older children and adolescents, proactive counseling focuses on positive physical and psychosocial development rather than pros and cons of body piercing.

●Patients contemplating piercing – When counseling patients who are thinking about body piercing but have not yet made up their mind, clinicians can:

•Encourage them to talk with others who have body piercings; friends of adolescents seem to have greater influence on decisions about body art than family members [9]

•Urge them not to make the decision under pressure, in haste, or while intoxicated

•Provide education and resources (table 1) to help them make informed decisions (see 'The piercing process' below)

•Discuss the motivational factors (ie, perceived benefits), costs, and potential risks; adolescents and young adults may obtain body piercing for a variety of reasons, including [4,9,13,18,20-23]:

-To redefine themselves

-To take control of their bodies and identities

-To be like their friends

-As means of sexual expression (for nipple or genital piercing)

-To feel unique

Costs and potential risks of piercing include [17,24,25]:

-Cost of the piercing procedure and jewelry

-Negative response from others (eg, parents, teachers, employers)

-Pain (no topical anesthetic is used for piercing)

-Infectious and noninfectious complications

It is particularly important for patients with congenital heart disease to understand their risk of infective endocarditis (especially with oral piercings), for patients with a bleeding disorder or receiving anticoagulant therapy to understand that they are at risk for prolonged bleeding (particularly with piercings that cross mucous membranes), and for patients with a personal or family history of keloids to understand their risk of keloid formation. In most cases, removal of keloids is considered cosmetic and could incur considerable out-of-pocket cost. (See 'Systemic infection' below and 'Skin reactions' below.)

●Patients who decide to obtain body piercing – When patients decide to proceed with body piercing(s), the clinician can help them make informed decisions about the site of piercing and the piercing artist [17,25,26]. The clinician can also provide anticipatory guidance about the need to remove jewelry before sports participation, complications, and indications for medical care. (See 'Health risks and considerations' below.)

The risk of specific complications may vary with the site of piercing. The site of piercing also may affect the ability to control who is able to see the piercing. For patients with bleeding disorders or who are receiving anticoagulant therapy, consultation with the specialist (eg, hematologist or other specialist managing anticoagulation therapy) is recommended before obtaining body piercing. (See 'Health risks and considerations' below and 'Site-specific considerations' below.)

Patients may be better able to choose a piercing artist/studio if they visit several studios to observe a piercing before making a decision. This allows the patient to see if the artist uses sterile technique (eg, uses disposable gloves and disposable or adequately sterilized needles, cleans the site with an antimicrobial solution) and provides appropriate aftercare instructions. (See 'The piercing process' below and 'Aftercare instructions' below.)

Regulations about the age of consent for body piercing differ from state to state and may vary according to the site of piercing. (See 'The piercing process' below.)

THE PIERCING PROCESS

●Piercing site and jewelry – Common sites of body piercing include the tragus or helix of the ear, eyebrow, nasal septum, nasal ala, lips, tongue, and umbilicus [27]. Nipple and genital piercing (table 2) is increasingly common in young adults [1,13,28]. Less common sites for piercing include the uvula, cheek, chest, neck, and knuckles.

Jewelry is typically made of metals with a low risk of contact dermatitis (eg, surgical stainless steel, niobium, titanium, gold). These metals may be combined with nickel or other metals to increase hardness or durability [25]. (See 'Skin reactions' below.)

●Piercing establishment and artist – Ear lobe piercing or piercing of the cartilage of upper one-third of the pinna (ie, "high-rim" piercing) frequently is performed at commercial establishments or kiosks in shopping malls. Most piercing at other sites is performed in tattoo studios [29].

Regulations for body piercing establishments and practitioners vary geographically [25]. Clinicians should become familiar with the regulations in their cities, counties, and states. In the United States, a compendium of state laws, statutes, and regulations is available from the National Conference of State Legislatures.

Body piercing may be performed by commercial or amateur practitioners. Amateur piercing may be performed by oneself or one's friends using crude instruments and poor technique, which may result in complications [24]. In most states, body piercing artists are unlicensed and formal training is not required.

The Association of Professional Piercers provides information and education for consumers, piercers, and health care professionals [30].

●Procedure – The skin typically is cleaned with an alcohol and iodine solution before it is pierced. In most cases, neither topical nor local anesthesia is applied.

The technique depends upon the anatomic site of the piercing, where the piercing is performed, and the level of experience of the piercer [24]. Studio piercers typically use straight, sterilized 12- to 16-gauge hollow-bore needles; after the hole is established, jewelry is guided through the hollow-bore needle using a string or wire [31]. Piercers who work in other commercial establishments or shopping mall kiosks may use a "cartridge-loaded" or "spring-loaded" gun for piercing the ear or ear cartilage; piercing guns cannot be properly sterilized and may damage the tissues that are pierced [31,32]. Although some reports suggest that piercing guns cause more damage to ear cartilage than piercing needles, a cadaver study found the pattern of injury to the cartilage and perichondrium to be similar regardless of piercing technique [33].

●Healing time – Healing times for body piercing vary according to site but can take as long as one year for umbilical piercings and certain genital piercings (table 2) and up to six weeks with ear piercing and other facial or oral piercings (including tongue piercings) [17].

PIERCING VARIATIONS — Piercing variations include:

●"Pocketing" – The ends of the piercing jewelry are embedded into the skin, leaving the middle of the shank exposed (figure 1).

●Ear gauging – The ear lobe piercing is slowly stretched to accommodate various types of jewelry (eg, plugs, tunnels) [34,35].

The initial piercing is performed as described above (see 'The piercing process' above), after which the piercee inserts a larger piece of jewelry every four to six weeks until the desired expansion is achieved.

●"Transdermal" or "microdermal" piercing – Part of the jewelry is placed below and part above the skin, which gives the appearance that the jewelry is stuck to the skin.

For transdermal piercings, the jewelry is screwed into an anchor that is inserted under the skin using a technique called "pocketing" (figure 2). The anchor contains holes through which tissue grows to secure it in place.

AFTERCARE INSTRUCTIONS — Piercings of the skin generally should be cleaned twice a day with antimicrobial soap and water for 10 to 15 days. Except for cleaning, contact with the site should be avoided [24,36]. Commercial aftercare products (eg, benzalkonium chloride-based products) may not have adequate microbicidal activity against Pseudomonas aeruginosa or may be contaminated with other microorganisms [32,37].

Aftercare of oral piercings involves using antiseptic (alcohol-free) mouthwash and ice chips or cool fluids to reduce swelling and pain during initial healing [38]. Patients with oral and perioral piercings should be regularly screened by a dental professional for complications [39].

HEALTH RISKS AND CONSIDERATIONS — Little information is available about the incidence of the complications of body piercing because complications are infrequently reported to state health departments or in the medical literature. Localized infections and skin reactions appear to be the most frequent complications; systemic infection also may occur [3,4,40].

Localized infection — Localized skin or cartilage infection is the most common infectious complication of body piercing, particularly umbilical and ear piercings [1,32,36,37,41,42]. In various surveys, the self-reported incidence of localized infection ranged from 10 to 45 percent [3,4]. Staphylococcus aureus and P. aeruginosa are the most frequently isolated pathogens [42,43]. An outbreak of mpox (monkeypox) at a piercing and tattoo establishment was associated with poor hygiene and aseptic conditions; among the 20 confirmed cases, 19 had piercings, 18 of which were ear piercings [44,45]. (See "Epidemiology, clinical manifestations, and diagnosis of mpox (monkeypox)".)

The risk of localized infection may be increased [41,42,46]:

●Soon after the piercing because of diminished skin integrity

●With high-rim ear piercings (because of the lack of vascularity); such complications may cause severe ear deformities

Outbreaks of P. aeruginosa auricular chondritis have been associated with contaminated aftercare solution and reported following piercing with spring-loaded piercing guns [31,32,37,47,48]. (See "Pseudomonas aeruginosa infections of the eye, ear, urinary tract, gastrointestinal tract, and central nervous system", section on 'Perichondritis'.)

Although there is little evidence to guide this decision, we generally suggest that piercings be removed during treatment of localized infection because of concerns about contamination of hardware. We also suggest discontinuation of commercial aftercare products (which may not have adequate microbicidal activity or may be contaminated with other microorganisms). (See 'Removal of jewelry' below.)

To avoid complications, either local or systemic antibiotics are advised promptly, depending upon the severity of cellulitis. We treat perichondritis of the pinna with topical and systemic antibiotics that provide activity against P. aeruginosa (eg, oral ciprofloxacin) and S. aureus (eg, topical mupirocin) [42,46]. We obtain wound cultures before initiation of systemic antibiotics to guide subsequent therapy if initial treatment fails [49]. Patients with perichondritis should be followed closely because of the increased risk of ear deformity [42,46]. The treatment of cellulitis is discussed separately. (See "Acute cellulitis and erysipelas in adults: Treatment".)

Systemic infection — The risk of systemic infection is increased in people who have had amateur body piercings or have not followed the aftercare instructions.

●Infective endocarditis – Infective endocarditis is a rare complication of body piercing, with a few new cases reported annually (among millions of body piercing procedures). Most cases involve oral piercings [50-62], but infective endocarditis also has been reported following umbilical [50,63-67], nipple [52], ear [68-70], and nasal piercing [51,71]. Cases have occurred in patients with a history of congenital heart disease, as well as in previously healthy individuals.

Various organisms have been involved, including methicillin-susceptible S. aureus [50,51,63,68], methicillin-resistant S. aureus [54,56], Staphylococcus epidermidis [52], Streptococcus viridans [57], Haemophilus parainfluenzae [55], Haemophilus aphrophilus (subsequently called Aggregatibacter aphrophilus) [53], and Neisseria mucosa [58].

Health care providers should consider the possibility of infective endocarditis in patients who present with unusual clinical events (eg, unexplained fever, rigors, weakness, myalgia, arthralgia, lethargy, or malaise) between one week and two months after body piercing [63]. (See "Infective endocarditis in children", section on 'Clinical manifestations' and "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis", section on 'Clinical manifestations'.)

The diagnosis and treatment of infective endocarditis are discussed separately. (See "Infective endocarditis in children".)

●Hepatitis – Hepatitis B and C can be transmitted during body piercing via reused or inadequately sterilized instruments; however, the magnitude of risk is not known [72]. In one survey of 766 college students with tattooing or body piercing, there were three cases of hepatitis (0.3 percent) [3]. In a systematic review, only 5 of 23 observational studies found an increased risk of hepatitis C among individuals with body piercing (the adjusted odds ratios ranged from 2.0 to 7.3) [73]. (See "Epidemiology, transmission, and prevention of hepatitis B virus infection" and "Epidemiology and transmission of hepatitis C virus infection" and "Screening and diagnosis of chronic hepatitis C virus infection".)

●HIV infection – HIV theoretically may be transmitted through body piercing, but there are no known cases of such transmission [74].

●Other systemic infections – Other systemic infections that have been reported after body piercing include:

•Tetanus [75,76]

•Streptococcal septicemia [77]

•Staphylococcal and streptococcal toxic shock syndrome [78-80]

•Mixed-oral-flora cerebellar abscess (after tongue piercing) [81]

Skin reactions — Skin reactions include:

●Allergic contact dermatitis – Allergic contact dermatitis (picture 1), particularly to nickel, is the most common noninfectious cutaneous complication of body piercing [82,83], occurring in approximately 40 percent of respondents in one survey [3]. (See "Clinical features and diagnosis of allergic contact dermatitis".)

Allergic contact dermatitis can be avoided by using jewelry that is made of 14K gold, surgical stainless steel, niobium, or titanium [17]. The treatment of allergic contact dermatitis is discussed separately. (See "Management of allergic contact dermatitis in adults".)

●Keloids and hypertropic scars – Keloids (picture 2A-B) and hypertrophic scars are less common cutaneous complications of body piercing [84-87]. Avoidance of body piercing may be warranted in patients with a family history of keloids, particularly if the person contemplating piercing is older than age 11 years. In a survey of 32 patients with keloids related to ear piercing, keloids were more likely when ear lobes were pierced at ≥11 years of age (12 of 15) than at <11 years (4 of 17) [88].

The epidemiology, pathogenesis, and management of keloids are discussed separately. (See "Keloids and hypertrophic scars".)

●Other skin reactions – Other skin reactions include sarcoidal reactions [89] and scleroderma [90].

Trauma — Tearing of the ear lobe may occur if the jewelry is pulled, gets caught, or is too heavy (picture 3) [91]. Friction from clothes and shearing forces during physical activity can produce abrasions [92,93]. Piercing hardware also may cause injuries (eg, abrasions, bruising) during physical or sexual activity [94].

Site-specific considerations

●Oral piercings – Rare, but potentially life-threatening, complications of oral piercings that have been reported include infective endocarditis [50-61], brain abscess [95], airway obstruction due to tongue swelling and edema [96], prolonged bleeding [97], interference with urgent endotracheal intubation [39,98], submandibular space infection (Ludwig angina) [99], and aspiration of jewelry [100,101]. (See 'Systemic infection' above.)

Local complications that have been reported after tongue and lip piercing include:

•Gingival recession (secondary to trauma) [102-107]

•Difficulty maintaining adequate oral hygiene, which may contribute to localized periodontitis [98,108-110] (see "Gingivitis and periodontitis in children and adolescents", section on 'Periodontitis')

•Increased salivary flow and drooling [98]

•Chipping, cracking, and fractures of the teeth [98,111,112] (see "Evaluation and management of dental injuries in children")

•Interference with chewing and swallowing [113]

•Speech impediments [92,114]

The prevalence of these complications is not known. In observational studies, the risk of local complications increased with time wearing oral jewelry; tooth-related complications appear to be more common with tongue than lip piercing; and the type of jewelry affects the risk of gingival recession and tooth chipping [107,115].

●Nasal piercings – Reported complications of nasal piercings include septal hematomas, granulomatous perichondritis, and aspiration or swallowing of jewelry [38].

●Nipple piercings – Reported complications of nipple piercing include breast abscess (picture 4) [116-118], toxic shock syndrome [79], and lactational difficulties [119]. Friction from clothes and shearing forces during physical activity can produce abrasions [120]. Reports of hyperprolactinemia with nipple piercing are inconsistent [121,122].

According to the La Leche League, women with healed nipple piercings can breastfeed [123]. Whether the jewelry is left intact during breastfeeding depends on the type of jewelry and the "latch-on" of the infant. Any jewelry that poses a risk of aspiration in the infant should be removed.

●Genital piercings – Reported complications of genital piercing (table 2) include prolonged priapism [124], paraphimosis [125], recurrent condyloma acuminata [126], streptococcal toxic shock syndrome [80], altered urinary flow [38], and compromised effectiveness of barrier contraception (eg, condoms, diaphragms) [25].

●Ear gauging – Restoration of ear cartilage after gauging may require surgical correction if this type of body art is no longer desired [34,35].

Pregnancy — Issues related to body piercing during pregnancy are discussed separately. (See "Maternal adaptations to pregnancy: Skin and related structures", section on 'Tattoos and piercing'.)

PREVENTION OF INFECTION — The risk of localized infection can be reduced when the person obtaining the piercing:

●Understands the procedure

●Obtains it in an establishment that uses sterile procedures

●Follows appropriate aftercare instructions for cleaning and maintenance (see 'Aftercare instructions' above)

Patients should complete hepatitis B immunization before body piercing. The risk of other systemic infections can be reduced if the piercing is performed by an educated artist who uses new needles with each piercing. (See "Hepatitis B virus immunization in infants, children, and adolescents" and 'The piercing process' above.)

The author of this topic review provides endocarditis prophylaxis for patients who plan to obtain a body piercing that crosses a mucous membrane (eg, oral piercing, genital piercing) and are at the highest risk for infectious endocarditis (eg, patients with prosthetic heart valves, previous infectious endocarditis, unrepaired cyanotic congenital heart disease, among others). Patients at highest risk and antimicrobial regimens are discussed separately. (See 'Systemic infection' above and "Prevention of endocarditis: Antibiotic prophylaxis and other measures".)

The American Heart Association does not recommend prophylactic antibiotics for patients with CHD before obtaining body art (tattoos or body piercings) [127]. However, prophylactic antibiotics have been suggested by clinicians who have cared for patients with CHD who developed infective endocarditis after body art, including members of professional societies [50,128-131].

REMOVAL OF JEWELRY

●Medical indications – Piercing jewelry may need to be removed temporarily because of swelling, infection, or radiologic or surgical procedures [92,132]. Urgent removal may be necessary in cases of trauma or loss of consciousness. Consensus about the need to remove oral or nasal jewelry before general anesthesia is lacking [133-136]. (See 'Localized infection' above.)

●Removal procedure – The procedure for removal of jewelry depends upon the type of jewelry, the reason for removal, and associated complications.

•Barbell and labret studs – Barbell studs have removable beads on either end of a straight or curved bar (picture 5); they are used in the tongue, eyebrow, umbilicus, nipple, clitoris, or glans penis. Labret studs are similar to barbell studs except they have a fixed disc on one end (picture 6); they are used in the tongue or lower lip with the bead end exposed.

Barbell and labret studs are removed by holding the bar with one pair of forceps and using another pair of forceps to unscrew the bead [132].

•Captive bead rings – Captive bead rings are a type of jewelry in which the bead fits into an opening in the ring that is slightly smaller than the bead; the bead is held in place by the tensile strength of the ring (picture 7). Captive bead rings are used for navel, nipple, and high ear piercings.

Captive bead rings are removed by holding the ring on either side of the bead and releasing the tension on the bead [137].

•Transdermal piercings – Transdermal piercings generally require skin incision for removal [138]. (See 'Piercing variations' above.)

•Surrounding edema – Compression of edematous tissue may permit removal of jewelry that is surrounded by edema; surgical excision may be necessary if compression fails.

More detailed information about removal of body piercings is available in the full text of reference [137].

●Maintenance of patency – To maintain patency of the piercing tract, the jewelry can be replaced with suture material, nonstick posts (available at design studios), or a nonmetallic intravenous catheter [137,139]. It is not known how long a piercing will remain open without jewelry if no attempt is made to keep it open. Several factors may contribute, including the amount of stretching and movement of the site.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Basics topics (see "Patient education: Keloids (The Basics)" and "Patient education: Tattoos and body piercings (The Basics)")

SUMMARY

●Epidemiology – Body piercing at sites other than the ear lobe is increasingly common among adolescents and young adults. (See 'Epidemiology' above.)

●Counseling – When counseling patients about body piercing, primary care clinicians can provide education and resources (table 1) to help them make informed decisions. This includes discussion of the motivational factors (ie, perceived benefits) and health risks, choice of the piercing site and artist, as well as anticipatory guidance about prevention of infection and injury, and when to seek medical care for complications. (See 'Counseling patients about piercing' above.)

●The piercing process – Body piercing may be performed by commercial or amateur artists. The piercing technique and aftercare instructions may affect the risk of complications. (See 'The piercing process' above.)

●Health risks – Health risks include localized infection, systemic infection, skin reactions, trauma, and site-specific complications (eg, related to oral, nipple, or genital piercings).

It is particularly important to discuss the possibility of infective endocarditis with patients with congenital heart disease (CHD) and keloid formation with patients with a personal or family history of keloids.

The author of this topic review provides endocarditis prophylaxis for patients who plan to obtain a body piercing that crosses a mucous membrane (eg, oral piercing, genital piercing) and are at the highest risk for infectious endocarditis (eg, patients with prosthetic heart valves, previous infectious endocarditis, unrepaired cyanotic congenital heart disease, among others). (See 'Systemic infection' above and "Prevention of endocarditis: Antibiotic prophylaxis and other measures".)

●Prevention of infection – The risk of infection can be reduced if the patient obtains the procedure in an establishment that uses sterile procedures, follows appropriate aftercare instructions, and completes hepatitis B immunization before the piercing. (See 'Prevention of infection' above.)

●Removal of jewelry – Piercing jewelry may need to be removed temporarily because of swelling or for radiologic or surgical procedures. Urgent removal may be necessary in cases of trauma or loss of consciousness. To maintain patency of the piercing tract, the jewelry can be replaced with suture material, nonstick posts, or a nonmetallic intravenous catheter. (See 'Removal of jewelry' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge R Michelle Schmidt, MD, MPH and Myrna L Armstrong, EDd, RN, FAAN, who contributed to an earlier version of this topic review.