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Guidance for the Clinician in Rendering Pediatric Care

CLINICAL REPORT

Adolescent and Young Adult Tattooing,


Piercing, and Scarification
Cora C. Breuner, MD, MPH,​a David A. Levine, MD,​b THE COMMITTEE ON ADOLESCENCE

Tattoos, piercing, and scarification are now commonplace among abstract


adolescents and young adults. This first clinical report from the American
Academy of Pediatrics on voluntary body modification will review the
methods used to perform the modifications. Complications resulting from
body modification methods, although not common, are discussed to provide aAdolescent Medicine Division, Department of Pediatrics, Orthopedics
the pediatrician with management information. Body modification will be and Sports Medicine, Seattle Children’s Hospital, University of
Washington, Seattle, Washington; and bPediatrics, Morehouse School of
contrasted with nonsuicidal self-injury. When available, information also is Medicine, Atlanta, Georgia
presented on societal perceptions of body modification.
State laws are subject to change, and other state laws and regulations
may impact the interpretation of this listing.

Drs Breuner and Levine shared responsibility for all aspects of writing
and editing the document and reviewing and responding to questions
and comments from reviewers and the Board of Directors, and
Tattoos, piercings, and scarification, also known as “body modifications,​” approve the final manuscript as submitted.

are commonly obtained by adolescents and young adults. Previous This document is copyrighted and is property of the American
reports on those who obtain tattoos, piercings, and scarification have Academy of Pediatrics and its Board of Directors. All authors have
filed conflict of interest statements with the American Academy
focused mainly on high-risk populations, including at-risk adolescents.‍1 of Pediatrics. Any conflicts have been resolved through a process
Tattooing and piercing of various body parts no longer is a high-risk– approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
population phenomenon, as evidenced by growing numbers of adults and involvement in the development of the content of this publication.
adolescents not considered at risk who have tattoos and multiple ear and Clinical reports from the American Academy of Pediatrics benefit from
body piercings. The Pew Research Center reports that in 2010, 38% of expertise and resources of liaisons and internal (AAP) and external
reviewers. However, clinical reports from the American Academy of
18 to 29 year olds had at least 1 tattoo, and 23% had piercings in locations Pediatrics may not reflect the views of the liaisons or the organizations
other than an earlobe.‍2 Of those with tattoos, 72% were covered and not or government agencies that they represent.
visible.‍2 Scarification is the practice of intentionally irritating the skin to The guidance in this report does not indicate an exclusive course of
cause a permanent pattern of scar tissue; data are not currently available treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
on the prevalence of scarification in the United States.
All clinical reports from the American Academy of Pediatrics
Although body modifications have become a mainstream trend, automatically expire 5 years after publication unless reaffirmed,
they still may be associated with medical complications and, among revised, or retired at or before that time.

adolescents, may also co-occur with high-risk behaviors. This first DOI: https://​doi.​org/​10.​1542/​peds.​2017-​1962
clinical report from the American Academy of Pediatrics on tattooing, Address correspondence to Cora C. Breuner, MD, MPH, FAAP. E-mail:
piercing, and scarification discusses the history of these methods of body cora.breuner@seattlechildrens.org
modification, educates the reader on methods used, reports on trends PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
in associated adolescent and young adult risk behaviors, differentiates
between nonsuicidal self-injury (NSSI) and body modifications, and
educates the reader about how to anticipate and prevent potential To cite: Breuner CC, Levine DA, AAP THE COMMITTEE ON
ADOLESCENCE. Adolescent and Young Adult Tattooing, Piercing,
medical complications. The report analyzes the literature about societal
and Scarification. Pediatrics. 2017;140(4):e20171962
acceptance of people with body modifications and perceptions that

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might potentially interfere with probability sample of adults found by navel (38%), tongue (13%), and
adolescents’ and young adults’ higher tattoo rates among younger nipple and genital (9%) piercings.
educational and career plans. Finally, versus older cohorts.‍4 Evidence on
guidance is provided to pediatricians sex differences in tattooing also A survey conducted among college
and, through the pediatrician, to varies, with tattoo prevalence among freshmen from Italy found that many
parents and adolescents and young women ranging from 22% to 23% students undergoing tattooing and/
adults about safety and regulations and prevalence among men ranging or piercing were unaware of the
regarding body modification should from 19% to 26%.4,​6‍ Among those associated health risks.‍12 Although
they wish to obtain tattoos, piercings, with a tattoo, most (86%) have most (60%) students knew about
or scarification. never regretted getting one, and HIV-related risks, less than half
30% said it makes them feel sexier. knew about possible infection
Other feelings attributed to having with hepatitis C (38%), hepatitis
History of Body Modification: a tattoo included feeling rebellious B (34%), tetanus (34%), or about
Tattooing, Piercing, and (25%), attractive or strong (21%), noninfectious complications (28%).‍12
Scarification spiritual (16%), healthier (9%), more These findings have similarly been
intelligent (8%), and athletic (5%).‍6 reported in a sample of medical
Although interest in body
students who had undergone
modification has increased
Estimates of tattooing and piercing piercing.‍13
recently, history teaches us that
body modifications are not new. among adolescents range by data Scarification is the practice of
Archeologists have found evidence of source and age group. One early intentionally irritating the skin to
tattoos, piercings, and scarification as study among high school students cause a permanent pattern of scar
far back as 2000 BC, when they were from 8 states found that 10% had tissue. Studies have been conducted
largely used as a form of art or to tattoos, and 55% expressed interest among international communities
identify group membership, such as in tattooing.‍7 In this sample, tattoos describing high rates of scarification,
a religious group or tribe. Although were commonly obtained around the yet no studies on scarification have
mostly used to describe loyalty, ninth grade, but there were reports been reported from the United
interests, and lifestyle choices, body of tattooing as early as age 8 years.‍7 States.‍14,​15
‍ In the 1990s and 2000s,
modification had also been used to Among adolescent clinic samples of there was some renewed interest in
label criminals, slaves, and convicts.‍3 youth 12 to 22 years of age, tattooing scarification as a movement to revive
ranged from 10% to 23%, and body indigenous rituals from around the
Although in the late 20th century, piercing (other than the earlobe)
most tattoos were on men, ranging world, embracing a more authentic
ranged from 27% to 42%,​‍8,​9‍ with or spiritual body experience.‍16
from the stereotypical tattooed higher rates of tattooing and body
sailors and motorcycle bikers (eg, piercing among girls versus boys and
The Hells Angels in the 1960s) older versus younger adolescents.8,​9‍
to 1980s gang members, now, Declining Strength of
Harris Poll data revealed that 22% of Associations With Risk Behaviors
tattoos are collections of colorful youth 18 to 24 years of age reported
ornamentations for both women and having a tattoo,​‍6 but estimates were Although in the past, body
men. Surveys of the US population as high as 38% among young people modification was often associated
have shown an increase in the 18 to 29 years of age on the basis of with adolescent high-risk behaviors,
prevalence of tattoos over time.‍4,​5‍ Pew Research Center findings.‍2 current data have not consistently
reported this association. In a
Findings are comparable among retrospective analysis from 2007 to
Epidemiology
subsequent samples of private 2008, tattoos were associated with
Harris Poll data from 2016 found that university and college students, of alcohol and drug use, violence and
3 in 10 US adults had at least 1 tattoo, whom 23% had a tattoo and 51% had weapons carrying, sexual activity,
up from 20% in 2012.‍6 Differences a body piercing.‍10,​11
‍ Male athletes eating disorders, and suicide.‍17
were found by geographic region, were more likely to be tattooed However, the scientific link between
with tattoos being more prevalent than male nonathletes, and although tattooing and risk behaviors is
in the West (27%) versus the East women were more likely to have less consistent today.‍1 As with any
(28%), Midwest (27%), and South a piercing than men, there was no adolescent or young adult, for those
(32%).‍6 Tattoos were also more difference by sex for tattooing.‍10,​11
‍ Of with piercings and tattoos, it is
prevalent among adults in their 30s students with current piercings, high- advised that the pediatrician conduct
compared with those younger and ear cartilage (53%) was the most a careful adolescent psychosocial
older,​‍6 although another national common visible piercing, followed history with targeted behavioral

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interventions to assist in decreasing among those with and without modification may be well advised to
risk behaviors.‍18 tattoos, 29% believed that people make sure that the tattoo or piercing
with tattoos were more likely to do is not visible in typical work attire.
something most people consider
Body Modification Is Not NSSI deviant, whereas 24% believed
this in 2012.‍6 From another survey Tattooing
It is important to be able to
distinguish normal body modification regarding technological and social Methods
from body modification that is changes, 40% of respondents said
that more people getting tattoos has A multitude of videos on YouTube
more dramatic or intense as part of
been a change for the worse, 45% and other Internet video repositories
NSSI syndrome, which is described
of respondents said that it has made exist for the reader to view and learn
in the Diagnostic and Statistical
no difference, and only 7% said this about safe and acceptable methods
Manual of Mental Disorders, Fifth
has been a change for the better. As of tattoo placement. After selecting
Edition as follows: “over the past
might be expected, older Americans or designing the art to be transferred
year, the person has for at least 5
are far more likely to negatively view via tattoo, it is stenciled or drawn
days engaged in self-injury with the
this trend; 64% of those 65 years on the skin. The skin is cleansed
anticipation that the injury will result
and older and 51% of those 50 to with antiseptic, and a thin layer of
in some bodily harm without suicidal
64 years of age said more people ointment (such as petroleum jelly)
intent.”‍19
getting tattoos has been a change is placed on the site. Professional
NSSI differs from body modification for the worse. A majority of those tattoo artists use a motorized,
because NSSI often is impulsive or younger than 50 years (56%) said the electric–powered machine that holds
compulsive and may be associated tattoo trend has not made much of a needles and can puncture the skin
with mental health disorders, difference.‍22 up to several thousand times per
including psychotic disorders, minute. The needles are dipped into
personality disorders, and anxiety The age differences are larger among the ink and then puncture the skin at
disorders.‍20 Estimated prevalence women than men. Of women aged a depth of a few millimeters, where
rates for NSSI in 2008 for adolescents 50 years and older, ∼6 in 10 (61%) the pigment reaches the dermis layer.
were between 14% and 24%. It can said more people getting tattoos Any blood or serosanguineous fluid
include cutting, scratching, burning, have been a change for the worse, is wiped away during the procedure.
and hitting oneself. Individuals who compared with 27% of younger After completion, another antiseptic
hurt themselves report injuries to women. The gap is smaller among is applied, and the tattoo is covered.
many different body parts.‍21 The men; 51% of men aged 50 years After 24 hours, the dressing is
individual who engages in self-injury and older said more people getting removed and the tattoo remains open
expects to get relief from a negative tattoos has been a change for the to air, and the skin is kept moist by
emotion, deal with a personal issue, worse, compared with 30% of applying antibiotic ointments, thick
or create a positive feeling.‍19 younger men.‍2 skin cream, or vitamin E oil several
Importantly, NSSI is clinically Although societal acceptance of times daily. If cleansing is necessary,
concerning because of an association tattoos and piercings has increased, the skin is blotted and not rubbed.
with mental health disorders, there still may be repercussions Tattoos generally take 2 weeks to
whereas body modification such when seeking employment or heal; sun exposure should be avoided
as tattooing, piercing, and/or educational opportunities. In a or sunscreen should be used, and
scarification does not have these 2014 survey of nearly 2700 people, swimming, direct shower jets, or
associations and is more socially 76% thought that tattoos and/or soaking in water should be avoided.
acceptable.‍19 Intention is the most piercings had hurt their chances Clothing that might adhere to the
important differentiator and can of getting a job, and 39% thought tattoo site should not be worn.‍3
be discerned with careful clinical employees with tattoos and/or The inks of tattoos are a mixture
interviewing.‍18 piercings reflect poorly on their of inorganic and synthetic organic
employers.‍23 One executive career pigments and diluents. They are
coach wrote that 37% of human considered cosmetics by the US
Perceptions of Community and resource managers cite tattoos as the Food and Drug Administration.
Potential Employers About third physical attribute likely to limit Metal salts are commonly used as
Tattooing and Piercing career potential (nonear piercings pigments; aluminum, cadmium,
Public opinion of the relationship and bad breath were the top 2).‍24,​25
‍ chromium, cobalt, iron, mercury,
between having a tattoo and deviant Consequently, adolescents and nickel, silicon, and titanium are
behavior is changing. In 2008, young adults contemplating body a few of the metallic elements in

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tattoo pigments.‍26 Although the The method of tattooing is similar to pruritus, papules, or nodules at the
concentration of metals in tattoo ink what is discussed previously. site. Pathologically, the reactions
is low, metals are emerging as a class include lichenoid, eczematoid,
of human carcinogens. Cutaneous Henna and Temporary Tattoos sarcoidal, and pseudolymphomatous
exposure over a lifetime may result The henna plant contains the pigment reactions as well as foreign-body
in adverse events. Risk is modified lawsone; in the skin, it interacts with granulomas. Preexisting conditions
by bioavailability, cellular uptake, keratin to give a reddish-brown color can lead to other reactions; psoriasis,
metal interactions, protein binding, (sometimes known as “red henna” to systemic lupus, and sarcoidosis
bone sequestration, and excretion. distinguish from “black henna,​” may demonstrate the Koebner
Age, sex, genetic variance, and other which is red henna mixed with phenomenon, leading to new
factors also appear to influence paraphenylenediamine [PPD]). Red lesions at the site of the tattoo.
potential toxicity.‍27 henna is commonly used in Islamic Even temporary henna tattoos have
and Hindu societies, especially for been associated with inflammatory
Unfortunately, many tattoos are reactions.‍31
celebrations such as weddings and
placed by amateurs, which makes
religious ceremonies. The henna
the process much riskier. In these
powder is mixed with a variety of Infections are a potentially more
cases, antiseptic processes may not
materials depending on the artist serious complication of tattooing.
be followed, leading to potential
and the region. They may include Tattooing can lead to infection
skin infections and transmission
essential oils, such as lemon or caused by contaminated tattoo ink
of bloodborne illnesses, such as
eucalyptus, the dried powder of or needles; inadequate disinfection
hepatitis C or HIV. Prison tattooing is
indigo plant leaves, lemon or beet of the skin to be tattooed, resulting
usually painful because of the use of
root juice, tannin from tea leaves, in resident bacterial contamination
typically blunt instruments that are
dried coffee, charcoal powder, during the tattooing process; and,
available. The generally poor quality
turpentine, PPD (discussed later), secondarily, during the healing
and obvious visual location tends to
or even animal urine. Henna also process, when injured tissue causes
stigmatize prisoners on release and
has been used in different ways for pruritus.‍32 Unfortunately, the real
may limit their chances of obtaining
medicinal purposes beyond the scope frequency of local infections after
employment (see the previous
of this report.‍30 tattooing is unknown. Infections
section about public and employer
perceptions as well).‍28 The pigments The paste is applied to the skin may be superficial pyogenic
are not standardized and may also and remains for 30 minutes to 6 infections, deep or severe pyogenic
contain more toxic materials as well hours; the longer the exposure, the infections, atypical mycobacterial
as contamination.‍27 darker the color. At that point, there infections, systemic or cutaneous
will be an orange stain, which will viral infections, or (rarely) cutaneous
darken over the next 2 to 4 days. A fungal infections. Systemic viral
Permanent Makeup
temporary tattoo will usually last for infections from bloodborne
Permanent makeup has become 2 to 6 weeks, until the outer layer of pathogens include hepatitis C,
an increasingly popular form of skin exfoliates.‍30 hepatitis B, and HIV. Superficial
tattooing. Permanent makeup pyogenic infections are usually
Complications related to Staphylococcus aureus
advertisers talk about the advantages
of being waterproof, not smearing, The rate of complications from or Streptococcus pyogenes, with
time saving, and hassle free. Some having tattoos placed is not known. common patterns of pustules or
people choose permanent makeup However, with the large number papulopustules along the tattoo
because of physical limitations, such of tattoos placed every day and lines. Infections are typically
as visual impairments or arthritis few reports of complications from present 4 to 22 days after tattooing.
of the hands or shoulders. Cosmetic clients who receive tattoos, the rate Infections range from cellulitis and
tattooing can also be an adjunctive is likely low. Most of the relevant small pustules to larger abscesses
to reconstructive surgery, such medical literature are case reports or that require surgical incision and
as nipple reconstruction after a reports of local clusters of infection. drainage. Management is similar
mastectomy or breast reduction Reported complications of tattoos are to other skin pyogenic infections.
surgery. It is also used to cover inflammation, infections (bacterial More severe pyogenic infections
scars, birthmarks, alopecia, and and viral), neoplasms, and rare remain rare, but there are case
vitiligo. Cosmetic tattooing also may reports of vasculitis. Inflammation reports of endocarditis, spinal
be attractive to patients who have is caused by sensitivity to tattoo abscess, erysipelas, gangrene, and
allergies to conventional cosmetics.‍29 pigments leading to focal edema, amputations.‍33

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There are many case reports than if they are placed by unlicensed The structure and redox potential of
of patients who have acquired individuals.‍41 lawsone is similar to naphthalene,
nontuberculous mycobacteria (NTM) There have been case reports of a potent oxidant of glucose-6-
infections after receiving tattoos.‍34,​35
‍ neoplasms associated with or after dehydrogenase (G6PD)-deficient
The infection usually is caused tattoo placement. Keratoacanthoma, cells. Topical application of red henna
by contamination of the ink or squamous cell carcinoma, basal cell may cause hemolysis in children with
equipment with nonsterile water.‍36 carcinoma, and leiomyosarcoma have G6PD deficiency. The hemolysis can
Infections with Mycobacterium been described occurring in areas of be life threatening, with symptoms
chelonae and Mycobacterium the skin with tattoo pigmentation. of pallor, lethargy, jaundice,
abscessus, which are rapidly growing It is not known whether this is a anemia, vomiting, tachycardia, poor
bacteria, have occurred from the coincidence or a causal effect. Tattoos peripheral perfusion, and shock.‍30
contamination of either inks or placed over melanocytic nevi can Black henna contains the chemical
diluents. NTM infections range from make it difficult to monitor to ensure PPD. No natural black henna exists.
mild inflammation with lesional there is no malignant transformation, PPD is added to accelerate the dyeing
rash, papules, or nodules to severe and both nevi and melanoma have and drying process (to 30 minutes),
abscesses requiring extensive and been reported in previously tattooed to strengthen and darken the color, to
multiple surgical débridements. skin.‍31 enhance the design, and to make the
NTM infections may require a
Rarely, there have been cases pattern last longer. These methods
minimum of 4 weeks of treatment
reported of acute cutaneous stain the skin black and have an
with 2 or more antibiotic agents.‍36
vasculitis in tattoo recipients appearance more like a real tattoo.
Examples of antibiotic agents that
occurring 10 to 14 days after Black henna is available worldwide,
have been used, with variable success
placement. The following symptoms lasts several weeks in the skin, and
and sensitivities, are amikacin,
were typical: chills, arthralgia, offers an alternative to permanent
ciprofloxacin and moxifloxacin,
myalgia, and purpuric rash. tattoos. It is painless, and because the
clarithromycin, minocycline,
Treatment is similar to the treatment skin is not punctured, there is no risk
tigecycline, cefoxitin, imipenem,
of other vasculitides.‍33 of introducing local or bloodborne
trimethoprim-sulfamethoxazole,
pathogens. However, there is a slight
and linezolid.35 Antibiotic sensitivity Researchers in one review article
(2.5%) risk of allergic reactions from
is important in designing a discuss toxicologic risks of tattoo ink,
skin sensitization. Once sensitized,
treatment plan.‍37 Consultation with including phototoxicity, substance
patients may experience allergic
an infectious disease expert for migration, and the possible metabolic
contact dermatitis from hair dyes
suspected NTM infection in a tattoo is conversion of tattoo ink ingredients.
that contain PPD. There are also
warranted. Also reviewed are the potential risks
reported cross-reactions to other hair
associated with cleavage products
Another case report described Herpes dyes, dyes used in textiles, rubber
formed during laser-assisted tattoo
compuncturum that developed 3 days chemicals, and local anesthetics.
removal.‍42
after tattooing; it was concluded that Some reported reactions were
this was a secondary infection in a Henna and Black Henna Temporary severe, requiring hospitalizations,
patient in whom S aureus also was Tattoos especially in children. Most reactions
detected. Antibiotic therapy, antiviral were at the site, but generalization
Red henna is relatively safe. From a
therapy, and pain management can occur. It takes several weeks for
population perspective, at least half
resolved the rash.‍33 reactions to subside despite topical
of the population of India has been
and sometimes oral corticosteroid
Bloodborne pathogens may exposed to henna in their lifetimes
therapy.‍30
occur after tattooing. Tattooing with negligible reported immediate
is associated with hepatitis B hypersensitivity reactions.‍43 When
Tattoo Removal
transmission, especially in teenagers they have occurred, it is not certain
with other high-risk behaviors.‍38 whether sensitivity is caused by The current increasing popularity
Tattooing also is associated the lawsone pigment, another of tattoos in the United States has
with higher rates of hepatitis C component of the henna leaf, or concomitantly spurred an increased
transmission.‍39 HIV transmission the mixture of components. There interest in tattoo removal, although
associated with sharing tattoo is more concern for hairdressers tattoo removal is not new. Egyptian
needles or reusing tattoo inks has who use henna in dyes because it mummies dating to 4000 BC have
been reported.‍40 If tattoos are placed may be an occupational hazard.‍30 evidence of attempted tattoo
in licensed parlors, infections are Treatment is similar to that of other removal. Ancient Greek authors
less likely to occur after tattooing hypersensitivity reactions. described the use of salt abrasion

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or a paste that also contained garlic described in a report, the patient of body piercing, some of which
and cantharidin to remove tattoos. elected to have another tattoo placed take the observer through the steps,
Relationships, social status, and to hide the burned area.‍47 including infection control practices.
aesthetic tastes may change. Not Most body piercing jewelry consists
Other methods that are less
all tattoos are placed intentionally; of rings, hoops, studs, or barbell-
commonly used for tattoo removal
penetration of exogenous pigments shaped ornaments. The size and
include mechanical and chemical
can occur from road dirt from an shape of jewelry is determined by
removal techniques. Mechanical
accident, graphite in pencils, or the body site pierced and personal
methods include dermabrasion
gunpowder, and many people may preferences. Jewelry is not always
(which is variably effective) and
want these unintentional tattoos interchangeable between piercing
excision with or without grafting
removed.‍44 Adolescents may sites. In particular, jewelry designed
(mostly for small tattoos; the
overestimate the effectiveness of for ear piercing may not be suitable
predicted scar remaining would
tattoo removal when having one for another part of the body because
have to be acceptable to the patient).
placed and should be instructed that of the length of the post or the
A number of chemical methods
tattoo placement is permanent, and it pressure exerted by the clasp.‍50
have been used with dermabrasion
is expensive and sometimes difficult
or as monotherapy. Imiquimod Most body piercing jewelry is made
to remove them.‍3 Tattoo removal
has been applied, with or without of metal, usually stainless steel, gold,
techniques can be categorized as
tretinoin, with mixed results. These niobium, titanium, or alloys. Gold
mechanical, chemical, ablative, and
techniques often result in hypo- or often is combined with nickel or
selective.‍44
hyperpigmentation, or scarring, with other metals to make alloys that have
varying effectiveness.‍44 improved hardness and durability.
“Q-switched” lasers are the current
Nickel in gold-filled or gold-plated
state-of-the-art tattoo removal Although laser removal may be the
jewelry is associated with a high
method. The laser wavelength is best way to remove a tattoo, the time,
prevalence of reactivity in people
adjusted to match the absorption needed treatments, and cost should
who are nickel sensitive. Those
pattern of the different color not be underestimated. One case
who are getting a piercing should
pigments. The Q-switched laser report noted a 29 year old patient
pay careful attention to the studs or
pulse is delivered over nanoseconds with 2 large, multicolored tattoos on
clasps on earrings; jewelry with a
with extremely rapid heating as his arms and chest who presented for
high karat rating commonly is paired
high as 900°C (1652°F), leading to removal. After 47 treatments, there
with less expensive gold-plated
fragmentation of tattoo pigment was significant improvement.‍48 There
studs or earring backs. Niobium and
particles. Immediately after the is no cost regulation of laser tattoo
titanium are light-weight elemental
pulse, the epidermis appears white removal, and price per sq in per
metals that rarely produce an
because the formation of gas as water treatment can be anywhere between
allergic response. Other features to
in the skin is vaporized. An acute $49 and $300 depending on the
consider in body piercing jewelry
inflammatory infiltrate surrounds location of the removal service. There
include the ease of removal (in case
the pigment and debris from are also standards published that
of trauma or radiographs), surface
fragmented cells. Tattoo particles involve the skin type and complexion
smoothness, and its capacity to
can be found in regional lymph of the individual, the colors involved,
withstand autoclaving and cleaning.‍51
nodes. Phagocytosis and clearance and complexity of the pattern adding
Surgical stainless steel rarely causes
of fragmented pigment particles up to a clinical score known as the
allergic skin reactions; however, not
ensues. Free pigment is intracellular Kirby-Desai score. A tattoo that is
all stainless-steel products are nickel
again within 4 weeks. Subsequent 15 sq in and is estimated to have 8
free.‍52
treatment should be performed after sessions based on this Kirby-Desai
at least 4 weeks. One single-session score could cost $5880, assuming a Although earrings may be sterilized
laser treatment is available. Longer cost of $49 per sq in.‍49 before use, most piercing guns are
intervals may reduce the risk of not sterilized between procedures.
permanent pigmentary changes to Ear piercing systems using
the skin.‍44,​45
‍ It is important to have Piercing and Stretching disposable, sterile cassettes are
the requisite training in the use of the available but are not always used.‍51
Methods
Q-switched laser for tattoo removal; Because body piercing salons are
the literature notes case reports A multitude of videos on YouTube unregulated in many states, some
of significant burns within tattoos and other Internet video repositories physicians may choose to perform
after treatment, leading to scarring exist for the reader to view and learn body piercing procedures in their
and poor outcomes.‍46 In one case about safe and acceptable methods own office settings.

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The lips, cheeks, and midline of the TABLE 1 Approximate Healing Times for Body to more severe infections, including
tongue are popular sites for oral Piercing Sites‍51 osteomyelitis, toxic shock syndrome,
piercings. Perforation of lingual Site (Piercing Name) Time to Heal and bacteremia. Life-threatening
blood vessels can cause bleeding Clitoris 2–6 wk infections as a result of complications
and hematoma formation. Edema Coronal ridge (dydoe) 6–8 wk associated with body piercing include
frequently develops after a tongue Earlobe and auricle 6–8 wk septic arthritis, endocarditis, and
piercing, so a longer barbell is Eyebrow 6–8 wk hepatitis B. With any piercing, there
Glans penis (ampallang) 3–9 mo
recommended initially.‍53 Switching is the danger of infection, including
Labia majora 2–4 mo
to a shorter barbell reduces the Labia minora 2–6 wk hepatitis B or C virus and tetanus.‍41,​61

damage to the dentition and gingiva. Lip 6–8 wk Body piercing as a possible vector
Of note, beaded jewelry may become Navel Up to 9 mo for HIV transmission has been
trapped between the teeth. Nipple 2–4 mo suggested, although no cases have
Scrotum (hafada) 2–3 mo
The ear is the most universal site for been reported.‍62,​63

Tongue 3–6 wk
body piercing. Multiple ear piercings Urethral meatus (Prince 2–4 wk
have gained approval, especially Albert) A serious consequence of oral
high piercing through the cartilage piercing is airway compromise
of the pinna. The nose can be pierced from trauma, tongue swelling, or
piercing, is defined as piercings
in the fleshy nares or through obstruction by jewelry.‍64 Securing
placed into a flat surface of the body.
the cartilaginous septum. Septal an adequate airway or endotracheal
The jewelry has an entry point and
piercings usually are performed in intubation can be challenging when
an exit point, but dermal piercing has
the inferior, fleshy part of the septum a patient has a tongue barbell.‍57,​65
‍ If
just one end that can be seen on the
and not through cartilaginous tissue. lingual jewelry cannot be removed
surface of the skin. The second end
The navel or periumbilical area is a easily or expeditiously, precautions
is studded into the dermal layer of
popular self-piercing site. Navel rings should be taken during intubation to
the skin. This variant of piercing has
and subsequent scarring are more ensure that jewelry is not loosened
gained a lot of popularity because it
problematic in overweight patients and aspirated or swallowed. Removal
can be placed on most flat surfaces of
and in the latter stages of pregnancy of oral and nasal jewelry also is
the body, and designs can be created
as abdominal girth expands. recommended before nonemergency
by putting together multiple dermal
surgical procedures. Chipping
Wearing a curved barbell instead piercings or combining with tattoos.
or fracturing of teeth is the most
of a ring until the navel piercing They may be difficult to remove and
common dental problem related to
has healed may reduce irritation may occasionally require surgical
tongue barbells.‍66
and scarring. Friction from clothing removal.‍55,​56

with tight-fitting waistbands and Although there is a risk of infection
subsequent skin maceration may Complications
because of the vast amounts
account for the delayed healing No reliable estimates are available of bacteria in the mouth, the
and increased infection rates of regarding people who have infection rate is low. Oral rinses
navel piercings. Careful placement experienced complications related (eg, Listerine; Johnson and Johnson
of jewelry and avoidance of rigidly to body piercing. Importantly, Consumer Companies Inc, New
fixed jewelry may minimize these adolescents and young adults with Brunswick, NJ) or the application
problems. Before nipple and areolae increased vulnerability to infection of nonprescription cleansers (eg,
piercings, men and women should (eg, patients with diabetes mellitus Gly-Oxide Liquid Antiseptic Oral
be counseled about the lengthy time or who are taking corticosteroids) Cleanser; GlaxoSmithKline Consumer
required for complete healing and the and those taking anticoagulant Healthcare, Philadelphia, PA) may be
risk of delayed infection (see ‍Table 1). medications may be at greater risk recommended prophylactically after
Genital piercings anecdotally have of complications from body piercing. an oral piercing.‍67
been reported to enhance sexual However, multiple adverse outcomes
sensitivity. Genital piercing sites in associated with body piercing have Ludwig angina is a rapidly spreading
men include the penile glans, urethra, been reported, including infection, oral cellulitis and has been reported
foreskin, and scrotum; sites in pain, bleeding, hematoma formation, as a complication of tongue
women include the clitoral prepuce cyst formation, allergic reaction, piercing.‍68 Treatment involves
or body, labia minora, labia majora, hypertrophic scarring, and keloid maintaining an adequate airway, the
and perineum.‍54 ‍ –60
formation.‍51,​57‍‍ administration of systemic antibiotic
Dermal piercing, also known as Infection severity ranges from local agents, and surgical drainage of
microdermal piercing or single-point infections (impetigo and cellulitis) abscesses.

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Of people with ear piercings, up to Johnson Consumer Companies Inc, heals.‍79 Similarly, a loop fashioned
35% had one or more complication New Brunswick, NJ]). Treatment from nylon suture material may keep
(eg, minor infection [77%], allergic with mupirocin ointment or oral a piercing intact during the healing
reaction [43%], keloid formation antistaphylococcal antibiotic agents process.
[2.5%], and traumatic tearing may be warranted.‍61 Oral antibiotic
[2.5%]).‍69 Auricular perichondritis agents, such as the first-generation Earrings can also become embedded
and perichondrial abscess typically cephalosporins (eg, cephalexin in the earlobe, a complication
occur in the first month after or cefadroxil and penicillinase- common in persons with thick,
piercing, especially during warm- resistant penicillins), are appropriate fleshy earlobes that are pierced
weather months.‍70 treatment options for more extensive with spring-loaded guns.‍80 Piercing
but uncomplicated skin and soft guns exert high pressure on the soft
Auricular perichondritis presents tissue of the earlobe and cannot be
tissue infections. Alternative
as painful swelling, warmth, and adjusted for varying tissue thickness.
antibiotic agents (ie, clindamycin or
redness in a portion of the auricle Embedding may be prevented by
trimethoprim-sulfamethoxazole) may
that often spares the earlobe. using longer earring posts with
be more appropriate in communities
Acute tenderness on deflecting adjustable backings. If gentle probing
that have higher rates of methicillin-
the auricular cartilage helps fails to locate an embedded earring, a
resistant S aureus cases. Guidelines
distinguish this deeper perichondrial small incision under local anesthesia
for the treatment of methicillin-
infection from a superficial skin (without epinephrine) may be
resistant S aureus, according to
infection. Minor infections can necessary to locate and remove the
the Infectious Diseases Society of
progress to perichondritis, abscess earring or backing. Any suspected
America, also suggest doxycycline or
formation, and necrosis with or infection should be treated.‍80
linezolid might also be appropriate.‍74
without systemic symptoms. The
An earring can be replaced, or the
most common pathogens (ie, Trauma to the pierced external ear
ear can be repierced 6 to 8 weeks
Pseudomonas aeruginosa, S aureus, is common. Lacerations to the ear
after resolution of local swelling and
and S pyogenes) often respond may occur after falls, motor vehicle
tenderness.‍51
well to fluoroquinolone antibiotic crashes, contact sports, person-to-
treatment (eg, ciprofloxacin or The earlobe is a common site for person violence, or accidental pulling
levofloxacin).‍71,​72
‍ Alternative options hypertrophic scarring and keloid of an earring. The simplest laceration
for hospitalization will depend on formation. In addition to aesthetic occurs when an earring is pulled
the pathogen and might include concerns, patients with keloids through the earlobe, especially if the
clindamycin, ceftazidime, and may have itching and tenderness. original earring hole was close to
cefepime. Treatment options for keloids include the periphery. All wounds should be
surgical excision, intralesional cleaned and repaired within 12 to 24
If an abscess is present, surgical
corticosteroid injections, hours. A simple earlobe tear can be
incision and drainage often are
cryosurgery, pressure dressing, sutured under local anesthesia. If the
necessary. Once an abscess develops,
radiation, and laser therapy.‍75,​76
‍ hole has closed, the earlobe can be
good cosmetic preservation of the
auricular cartilage is difficult to Contact dermatitis resulting from repierced in an unscarred area after
maintain. nickel exposure is common. Contact ∼3 months.‍81
sensitivity to gold and localized
Prolonged wearing of heavy jewelry Various closure techniques have been
argyria, a skin discoloration resulting
also may result in an elongated tract described in the literature. More
from silver salts, also have been
or bifid deformity of the earlobe. complex lacerations of ear cartilage
described.‍77,​78
‍ Avoidance of the
People with atopic dermatitis or should be referred to subspecialists
metals that trigger a reaction and the
allergic metal contact dermatitis are for repair.‍82
application of topical corticosteroids
at increased risk of developing minor hasten the resolution of allergic Pointed earring posts may cause
staphylococcal or streptococcal skin dermatitis. pressure sores or postauricular skin
infections.‍73
Occasionally, inflammation or irritation when worn during sleep.
Superficial earlobe infections tend infection result in such significant The removal of jewelry at bedtime is
to have a benign course and respond swelling that an earring should be indicated if switching to a different
well to local treatment, including removed. The pierced hole can be earring style does not resolve the
warm, moist packs and application of maintained, if desired, by inserting problem. Parents of infants or young
over-the-counter, topical antibiotic a ring made from a 20-gauge Teflon children with pierced ears should be
ointment (eg, bacitracin [Polysporin catheter with silicone tubing into informed of the risk of aspiration and
and Neosporin; Johnson and the hole while the surrounding skin ingestion of earring parts. In such

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20, 2017
situations, earrings with a locking TABLE 2 Potential Complications of Body Piercings‍51
back or screw back are advisable.‍83 Piercing Site Potential Complications
A localized infection of the earlobe Ear Allergic reaction, auricular perichondritis, embedded earrings, infection,
may not be easily differentiated from keloid formation, perichondral abscess, and traumatic tear
Genitals (women) Allergic reaction, compromise of barrier contraceptives, infection, and keloid
allergic contact dermatitis unless
formation
there is purulent drainage or a high Genitals (men) Frictional irritation, infection, paraphimosis, penile engorgement, priapism,
index of suspicion.‍78 recurrent condyloma, urethral rupture, urethral stricture, and urinary flow
interruption
Piercing the nasal cartilage can cause Mouth Airway compromise, altered eating habits, gingival trauma, hematoma
significant bleeding and lead to septal formation, increased salivary flow, infection, injury to salivary glands,
hematoma formation that often is interference with radiographs, loss of taste, Ludwig angina, pain,
accompanied by infection. Other permanent numbness, speech impediments, tooth fracture or chipping, and
potential complications that may uncontrolled drooling
Navel Bacterial endocarditisa, frictional irritation, infection, and jewelry migration
result in cosmetic deformities include and rejection
perichondritis and necrosis of the Nipples Abscess formation, bacterial endocarditisa, breastfeeding impairment, and
cartilaginous nasal wall. Infection infection
requires aggressive treatment with Nose Infection, jewelry swallowing or aspiration, perichondritis and necrosis of the
antibiotic agents that have good nasal wall, and septal hematoma formation
coverage against Staphylococcus
a In patients with moderate- to high-risk cardiac conditions.

species that commonly colonize


the nasal mucosa. Mupirocin is replace a retracted foreskin) has who has had a medical or health
effective and offers excellent been associated with urethral and problem related to body piercing;
coverage against Gram-positive cocci. glans piercings in uncircumcised they most commonly reported
Fluoroquinolones have the advantage men.‍88 The foreskin may be reduced infections (74%), bleeding (30%),
of excellent skin penetration and manually after a penile nerve block. allergic reactions (26%), and bruising
added coverage against Pseudomonas If this maneuver is unsuccessful, and keloids (19% each) (see ‍Table 2).
species.‍84 the prepuce can be injected Among those subjects with body
with hyaluronidase to allow the piercings, 12% reported having had
Nasal jewelry has the potential to
edematous fluid to dissipate.‍89 personal experiences with health
be aspirated or swallowed. Rings
problems related to the piercing,
placed in the nostril or septum also Penile rings also can cause
including infections, bleeding,
can migrate forward or be pulled engorgement and priapism (ie,
bruising, and allergic reaction.
out. As with ear piercing, the studs or persistent erection), requiring
Interestingly, those who got their
backings of the jewelry may become emergency treatment to preserve
piercings in a body-piercing shop
embedded and require surgical erectile function. Women with genital
were far more likely to report having
removal.‍84 Abscess formation has piercings can develop bleeding,
had an infection (18.4%) than those
been reported after nipple piercing.‍85 infections, allergic reactions, keloids,
who got pierced elsewhere (1.9%).‍92
and scarring.‍90
There are case reports of cellulitis
Adolescents were asked to estimate
and spread of infection around a It is advisable that sexually active
the percent chance of having a
breast implant after a piercing.‍86,​87
‍ people with genital piercings
piercing-related health problem.
However, little information is be counseled that jewelry may
The perceived risk for piercing by
available about nipple piercing compromise the use of barrier
a professional (34%) was lower
after breast implantation or chest contraceptive methods. Condoms
compared with a nonprofessional
wall augmentation. The effects of may be more prone to break, and
(73%). Neither those with a piercing
nipple piercings on lactation are diaphragms may be more easily
nor those who had a problem
not clear, but jewelry or scar tissue dislodged during sexual activity
with a piercing perceived risk any
could impair latching on or block when 1 or both partners have genital
differently. Those who had pierced
a milk duct and adversely affect an piercings. Avoiding jewelry with
themselves perceived much less risk
infant’s ability to breastfeed. Nipple sharp edges and using looser-fitting
from piercing by a nonprofessional
piercings should be removed to condoms or double condoms may
(50%) than those who had been
avoid aspiration by the infant during help avoid some of these problems.‍91
pierced but not by themselves. Those
lactation.
From a unique study on urban with piercings of the face (nose,
Jewelry inserted through the glans teenagers and their knowledge of eyebrow, lips, and chin) tended to
penis may interrupt urinary flow. piercing complications,​‍92 33% of all perceive less risk for face piercing
Paraphimosis (ie, the inability to subjects reported knowing someone (41.5%) compared with those

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without (49.7%). In the analysis of generally carved for ear stretching, point of no return, and the hole will
perceived risk, there were no effects but other organic materials that not close to a standard piercing size if
of race, sex, or age.‍92 had the right shape naturally, from the “plug” is removed.
shells to teeth and claws, were also The typical jewelry worn in a
In a recent review from 2012, similar
used. large, stretched piercing is a plug,
complications were confirmed,
including systemic infections (such Many cultures have practiced sometimes incorrectly referred to
as viral hepatitis and toxic shock stretching, including ancient as a gauge, which refers to the sizing
syndrome) and distant infections Egyptians (eg, King Tutankhamen), system used in the United States. It
(such as endocarditis and brain Buddhists from Nepal, Mursi tribal is solid, usually cylindrical, and may
abscesses).‍58 It was recommended women of Ethiopia, and the African be flared out at one or both ends
that body piercers have their clients Maasai from Kenya and Tanzania. (saddle shaped) or kept in place by
complete a medical and social history Stretching is also apparent in the o-rings fastened around the ends. A
to identify conditions that may Easter Island heads. Historically, variation on this is the flesh tunnel,
predispose them to complications. the practice has been used for the which is shaped in the same way
Piercing candidates should choose purpose of tribal status, to scare but is hollow in the middle. Claw-,
a qualified practitioner to perform enemies in war, and for beauty talon-, and spiral-shaped pieces
their piercings.‍58 purposes. It has been and still is are also commonplace. Ear weights
a common practice for both men in varying degrees of size are also
One small study of children and and women. For men, it has been worn, commonly made from silver or
adults with congenital heart disease used historically to indicate the bronze, although other metals, such
found no cases of endocarditis after standing members of a specific as copper or brass, are occasionally
ear piercing, although only 6% of tribe. The bigger the stretching, the used. However, some people are
the patients received prophylactic higher the ranking the man had. As easily irritated by some metals;
antibiotic treatment.‍93 for women, ear stretching is more therefore, care should be taken when
There have been recent reports of for decorative purposes and also metal jewelry is worn. Ear cuffs (such
bacterial endocarditis after nipple signifies when a girl has reached as the gold ones used in South Indian
and navel piercings in patients with womanhood. These practices are provinces) or wrapped bead work
surgically corrected congenital still important and used today by (common among the Maasai of East
heart disease. It is important for many tribes and cultures.‍50 Africa) are other options, although
physicians to know about planned Stretching, in the context of body these are not usually seen in modern
piercings so they can consider piercing, is the deliberate expansion Western contexts.‍50
antibiotic prophylaxis in patients of a healed piercing for the purpose With both body piercing and
with moderate- or high-risk of wearing certain types of jewelry. stretching, the system of gauges and
cardiac conditions,​‍94–‍ 96
‍ although Ear piercings are the most commonly inches is used in gauge size notation,
the American Heart Association stretched piercings, with nasal which was originally meant for wire
guidelines on endocarditis septum piercings, tongue piercings, thickness determination. A gauge
prophylaxis do not specifically and lip piercings and lip plates number denotes a thickness on a
mention the need for antibiotic following close behind. Although all standardized scale, which, for most
agents in people contemplating ear piercings can be stretched to some purposes, starts at 20 gauge (0.03
or body piercings.‍97,​98 degree, cartilage piercings are usually in or 0.81 mm). This is most often
more difficult to stretch and more used for the nose and ear post studs.
Stretching Methods likely to form hypertrophic scars if Importantly, as the gauge number
Ear stretching is a modification stretched quickly. Dermal punching decreases to 0 gauge or even 00
practiced by and originating from is generally the preferred method gauge, the thickness of the piercing
indigenous peoples. Tribes in for accommodating larger jewelry in increases.‍50
various countries in Africa, Eurasia, cartilage piercings.‍50
America, and other indigenous Stretching should be performed in
Regulation of Tattooing and Piercing
lands have practiced the ritual small increments to minimize the
of ear stretching for cultural, potential for damaging the healed Although no reliable estimates exist
religious, and traditional purposes. piercing or creating scar tissue. In for the frequency of complications,
Ear stretching is a ritual that has North America, most stretching the risk of adverse effects can still
been practiced by people all over methods go up by a single, even-sized be reduced by ensuring sanitary
the world since ancient times. gauge increment at a time. Stretching tattoo parlors, needles, and inks;
Bone, horn, wood, and stone were to 2 gauge, or 6 mm, is considered the comprehensive training of artists;

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and strong infection-control TABLE 3 Body Piercing and Tattooing of Minors: Consent and Physical Presence Requirements by
practices. Individual states have State‍101,​ ‍102
regulated tattooing for decades to Type of Outright Prohibition Consent Required Parental Presence Required
address public health concerns. Procedure
States did not have any common Tattooing Alaska, California, Alabama, Arizona, Arizona, Arkansas, Indiana,
standards until 1999, when the Georgiaa, Iowab, Arkansas, Colorado, Kansas, Louisiana,
National Environmental Health Idahoc, Illinoisa, Connecticut, Delaware, Nebraska, North Dakota,
Maine, Mississippi, Florida, Hawaii, Ohio, Pennsylvania,
Association published Body Art: A
New Hampshire, Indiana, Kansas, Rhode Island, Virginia,
Comprehensive Guidebook and Model New York, North Kentucky, Louisiana, Wyoming (n = 12)
Code.‍99 This was an interdisciplinary Carolina, Oklahoma, Michigan, Minnesota,
collaboration of academics, public Rhode Island, South Missouri, Montana,
health professionals, professional Carolinad, Tennesseee,​f, Nebraska, New Jersey,
Washington, Wisconsina North Dakota, Ohio,
organizations, physicians,
(n = 17) Pennsylvania, South
environmental health experts, and Dakota, Texasf, Utah,
body art practitioners. The model Vermont, Virginia, West
provided detailed recommendations Virginia, Wyoming
for and guidelines on sanitation and (n = 28)
Body piercing Idahog, Mississippi, South Alabama, Alaska, Arizona, Arizona, Arkansas,
infection control. Artist training
Carolina (n = 3) Arkansas, California, Indiana, Kansas,
should include competence in Colorado, Connecticut, Louisiana, Nebraska,
sterilization procedures, anatomy, Delaware, Florida, New Hampshire, North
and infection control. As of 2012, Georgia, Illinois, Dakota, Ohio, Oklahoma,
41 states each had at least one Indiana, Kansas, Pennsylvania, Rhode
Kentucky, Louisiana, Island, Tennessee, Texas,
statute in place regulating tattooing.
Maine, Michigan, Virginia, Wyoming (n
The remaining 9 states delegate Minnesota, Missouri, = 16)
authority to local-level and individual Montana, Nebraska,
jurisdictions within those states. New Hampshire, New
Even with these regulations, 72% Jersey, New York,
North Carolina, North
of states do not effectively regulate
Dakota, Ohio, Oklahoma,
sanitation, training and licensing, Pennsylvania, Rhode
and infection control. Training and Island, Tennessee,
licensing was the least consistently Texas, Utah, Virginia,
regulated topic. Pediatric health care Wyoming (n = 35)
providers are recommended to learn a The prohibition does not apply when the tattooing is performed by a physician or licensed technician under a physician’s

supervision.
about regulations in local states or b Prohibition applies only to unmarried minors.

jurisdictions.‍100 c Prohibition for those younger than 14 years, consent required for ages 14–18 years.
d Prohibition for those younger than 18 years, consent required for ages 18–21 years.
e Prohibition for those younger than 16 years, consent required for ages 16–18 years.
Similarly, there has been f Tattooing is allowed only for covering up an existing tattoo.

considerable debate about g Prohibition for those younger than 14 years, consent required for ages 14–18 years.

adolescents who are minors


obtaining tattoos and parental
consent requirements (‍Table 3). At not permitted on a person younger to minors obtaining tattoos and
least 45 states have laws prohibiting than 18 years without consent of that piercings in their states.‍101
minors from getting tattoos. Thirty- person’s parent or legal guardian.
eight states have laws that prohibit The consenting individual needs to
Scarification
both body piercing and tattooing on be physically present at the time of
minors without parental permission. piercing, provide evidence of status Methods
Each state varies on legislation of as parent or legal guardian, and sign
body piercing and tattooing.‍101 It a document that provides informed Scarification involves cutting,
has been a challenge for states to consent. Penalties for violators are burning, or branding words or
keep pace with the new body art fines, prison time, or both; most of images into the skin. Although many
forms. Almost every state has laws these laws define violators as the people who have scarification have
addressing some aspect of body art. person who performed the tattoo it done by amateurs, professional
Nevada has no laws addressing body or piercing. Pediatric health care practitioners of this type of body
art; Maryland has limited laws. In providers are encouraged to educate modification use a variety of
New Hampshire, body piercing is themselves about laws related methods. The purpose is to create a

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permanent body modification. Some Advice for Pediatricians consultation with an infectious
practitioners will also use methods disease specialist is warranted;
that enhance scar formation, such General Issues
as scraping off scabs or irritating 5. Lesions that appear to grow
1. Pediatricians should recognize and/or change within a tattoo are
the wound with materials such as the difference between voluntary
iodine, citrus juice, or toothpaste. an indication for evaluation for
body modifications and the neoplasms;
In some traditional cultures, ash impulsive NSSI syndrome; and
or clay is packed into the wound 6. Pediatricians should inform
to encourage hypertrophied scars. 2. As with all adolescent decisions families of the risk of hemolysis
There are many methods in use, that involve significant with red henna temporary
including the following: hot and consequences, it is recommended tattoos for children or others
cold branding (the latter with liquid that adolescents speak with their with a positive G6PD deficiency.
nitrogen), moxibustion (placing parents, guardians, or other Black henna temporary tattoos
incense on the skin and allowing responsible adults before having should be avoided because of the
it to burn until it’s extinguished tattoos placed. significant rate of sensitization;
in the skin), cutting with a scalpel,
7. It may be advisable for
thermo- and electrocautery, and Tattoos and Henna pediatricians to familiarize
laser branding.‍103
themselves with local laws and
1. Adolescents and their families
regulations related to tattooing to
Complications should be informed that tattoos
inform families should pediatric
are permanent and that removal
Scarification does not produce patients be interested in having
is difficult, expensive, and only
consistent results and does not tattoos placed; and
partially effective;
always produce the outcomes 8. Adolescents should be counseled
desired. Infection is a possible 2. Pediatricians should advise about the implications on job
complication of any of these adolescents with a history of placement and maintenance and
methods. Scarification artists keloid formation to avoid body education if the tattoos are at all
may not be as experienced with modifications that puncture the visible.
these processes perhaps because skin. The outcome is uncertain
of less demand for this method.‍3 whenever there is trauma to the Piercings and Stretching
Additionally, keloids may be a skin resulting in scar;
1. Rinsing with nonprescription
complication (essentially, keloid
3. Pediatricians should advise oral cleansers or the topical
formation is the complication of
their adolescent patients application of cleansers is
any of these body modification
to assess the sanitary and hygienic recommended to prevent infection
methods). There are emerging
practices of the tattoo parlors and after oral piercing;
treatment strategies for keloid
scars, but the best strategy is tattoo artists. This would include 2. Antibiotic agents with good
prevention. People who have had observing the use of coverage against Pseudomonas
keloids or have family members new, disposable gloves; the and Staphylococcus species (eg,
with keloids should be informed removal of the new needle and fluoroquinolones) are advised
that the outcome of scarification is equipment from a sealed, sterile when treating piercing-associated
uncertain.‍104 container; and the use of fresh, infections of the auricular cartilage;
unused ink poured into a new,
Regulation of Scarification disposable container with each 3. At clean piercing establishments,
new client; the piercer should be observed
Although not as regulated as putting on new, disposable gloves
tattooing, the amount of state 4. Pediatricians should advise and removing new equipment
regulation regarding scarification adolescents to seek medical care from a sterile container;
is increasing. As of February 2014, if there are signs and symptoms
4. Adolescents contemplating a
4 states prohibit scarification, and of infection. Normal skin and
tongue piercing should be advised
16 other states’ legislation could soft tissue infections should be
of the high incidence of tooth
be interpreted as regulating or considered first, but if there are
chipping associated with these
prohibiting scarification. Eleven any unusual features, prompt
piercings;
other states have some regulation as evaluation by a dermatologist
part of body art practice. Nineteen is recommended. If there is 5. Pediatricians play an important
states do not address scarification.‍104 confirmed mycobacterial infection, role in promoting injury

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20, 2017
prevention by recommending About.com Tattoos: tattoo.about.com; Dyer, IN: Peds-R-Us Medical
that all jewelry be removed US Food and Drug Administration. Education; 2013 (includes DVD).
during contact sports to avoid Think Before You Ink: Are Tattoos Available at: www.​peds-​r-​us.​com.
endangering the wearer and other Safe? http://​www.​fda.​gov/​
players. Jewelry that interferes ForConsumers/​ConsumerUpdates/​ Lead Authors
with mouth guards or protective ucm048919.​htm; Cora C. Breuner, MD, MPH, FAAP
equipment should be removed David A. Levine, MD, FAAP
before play. Nipple jewelry should US National Library of Medicine.
be removed before breastfeeding; Piercing and Tattoos: https://​ Committee on Adolescence, 2016–2017
medlineplus.​gov/p
​ iercingandtattoo​ Cora C. Breuner, MD, MPH, FAAP, Chairperson
6. It is important for pediatricians s.​html; and Elizabeth M. Alderman, MD, FSAHM, FAAP
to understand local laws and Robert Garofalo, MD, FAAP
regulations related to piercing to Healthy Children: https://​www.​ Laura K. Grubb, MD, FAAP
inform families should pediatric healthychildren.​org/​English/​ages-​ Makia E. Powers, MD, MPH, FAAP
patients be interested in having a stages/​teen/​Pages/​Tattoos.​aspx. Krishna K. Upadhya, MD, FAAP
Stephenie B. Wallace, MD, FAAP
piercing; and Books
7. Adolescents should be counseled Former Committee Member
Nagle J. Why Do People Get Tattoos
about the implications on job and Other Body Art? New York, NY: David A. Levine, MD, FAAP
placement and maintenance and Rosen Publishing; 2011;
education if the piercings are at all Liaisons
visible. Baily D. Tattoo Art Around the World. Laurie L. Hornberger, MD, MPH, FAAP – Section on
New York, NY: Rosen Publishing; Adolescent Health
Scarification 2011; and Liwei L. Hua, MD, PhD – American Academy of
Child and Adolescent Psychiatry
1. Teenagers with a personal or Spalding F. Erasing the Ink: Getting Margo A. Lane, MD, FRCPC, FAAP – Canadian
family history of keloids should Rid of Your Tattoo. New York, NY: Paediatric Society
be cautioned about the risk Rosen Publishing; 2011. Meredith Loveless, MD, FACOG – American College
of Obstetricians and Gynecologists
associated with scarification
Seema Menon, MD – North American Society of
and other body modification Body Piercings Pediatric and Adolescent Gynecology
processes; and Web Sites
Staff
2. Infections resulting from Association of Professional Piercers:
scarification may be treated Karen S. Smith
www.​safepiercing.​org;
James D. Baumberger, MPP
similar to other skin and soft
US National Library of Medicine.
tissue infections, with standard
Piercing and Tattoos: https://​
topical or systemic antibiotic
medlineplus.​gov/p
​ iercingandtattoo​
agents.
s.​html; and
Healthy Children: https://​www.​
Resources for Information About healthychildren.​org/​English/​ages-​ Abbreviations
Tattoos and Body Piercings stages/​teen/​Pages/​Body-​Piercing.​ G6PD: glucose-6-dehydrogenase
Tattoos aspx. NSSI: nonsuicidal self-injury
Web Sites Books NTM: nontuberculous
mycobacteria
Alliance of Professional Tattooists DeBoer S. Body Piercing Removal:
PPD: paraphenylenediamine
Inc: www.​safe-​tattoos.​com; Healthcare Professionals Handbook.

Copyright © 2017 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Adolescent and Young Adult Tattooing, Piercing, and Scarification
Cora C. Breuner, David A. Levine and THE COMMITTEE ON ADOLESCENCE
Pediatrics originally published online September 18, 2017;

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Adolescent and Young Adult Tattooing, Piercing, and Scarification
Cora C. Breuner, David A. Levine and THE COMMITTEE ON ADOLESCENCE
Pediatrics originally published online September 18, 2017;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
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