“Look at what we have here,” the scrub nurse exclaimed as she began a surgical prep on the young woman who was scheduled for a laparoscopy. The patient had a navel ring and a rose tattooed on her abdomen. “Do I have to take the ring out of my navel?” the patient asked. “I just had that done. I didn’t think of it when they asked me to remove my jewelry.” In a quiet, embarrassed tone, she questioned, “Will the doctor cut my tattoo when he does my surgery?” Scenes such as this are becoming more common with the rising incidence of body adornment with piercing and tattooing.

The popular press and media reflect the popularity of piercing as body adornment or body art among many different people.¹ Recent surveys suggest that tattoos adorn almost 20 million Americans — more than 13% of the general population.^2,3 Approximately one-half of tattoos are currently created on women from all walks of life, including professional and business women.⁴ Tattooing is also fashionable among adolescents, many of whom receive their tattoos from friends or who tattoo themselves.^5,6 However, there’s more lay information about this topic on the Internet than published research in the healthcare literature.⁷

Nurses in many healthcare settings frequently encounter patients who have some form of body adornment. Heightened awareness of piercing and tattooing will enable nurses to approach these patients in a nonjudgmental, open, and therapeutic manner and to provide appropriate interventions.

Piercing Art

Body piercing dates back to the Egyptians, Mayans, and Romans as a sign of courage and potency.⁸ England’s royalty flaunted body piercing during the Victorian era. Prince Albert, the husband of Queen Victoria, wore a penile ring.⁹ Over the past 20 years, the practice has become common in the U.S. as a form of self-expression. Previously identified with those outside of society’s mainstream, body piercing is gaining widespread popularity, especially among adolescents.²

Body piercing and its effects on health are not well studied or documented. Unlicensed personnel may perform piercing, which is learned from magazines, videos, and other piercers.⁷ Over the past several years, many states and their legislative bodies have recently instituted or are in the process of formulating and implementing body art regulations.¹⁰ As of 2006, 46 of the 50 states have established legislature regulating the body art industry. Five states address tattooing, but not piercing. Four states have passed legislation with specific state-wide rules; the remaining states require local health departments to regulate the industry.¹⁰ Two common topics addressed in the laws include training for the body artist and acceptable age of consent for the customer.¹⁰ For minors requesting body modification, required parental supervision, simple parental written consent, or complete outlaw of the practice on minors differ throughout the nation.¹⁰ The Association of Professional Piercers, an alliance of body artists, exists to provide current information on piercing procedures, sterile technique, and jewelry and operation standards.¹¹ This association is not federally regulated and may or may not assist in an artist’s required certification and regulation. Ear piercing is frequently performed in beauty salons or jewelry stores, and body piercing often takes place in tattoo establishments. Although they may be trained and instructed, compliance with aseptic practices is solely dependant on the piercers. In light of an insufficiently regulated industry, uninformed clients have difficulty knowing if the piercer follows proper procedures and uses the right equipment for sterilization.

Common piercing sites include the ear, nose, lip, chin, tongue, cheek, and eyebrow as well as the nipple, navel, and genitals. Less frequent body piercings include flat surfaces, such as the chest wall or hand web, which have a high incidence of rejection.¹² The jewelry for body piercing must be made of surgical grade steel, niobium, titanium, or 14K or 18K gold; other jewelry may cause skin reactions due to brass or nickel in the metal.⁹ Hollow, sterile needles of 6- to 18-gauge are used for the procedure.¹³ The tissue is punctured, and the jewelry is then inserted. Needles should be disposed of after each use and placed into a biohazard sharps container. The use of ear-piercing guns is highly discouraged because the instruments cannot be sterilized in an autoclave after each use, and microscopic pieces of tissue, blood, or other body fluids can be transmitted from person to person.¹⁴ Some businesses encourage their artists to enclose the machine in a plastic sheath to protect it from splatters, decreasing the risk of disease transmission.¹⁵

Depending on the body location, the average healing time for a piercing is two to eight months. The “seasoning” of the hole takes almost another year. Sites that heal the most quickly (in six to eight weeks) are the ears, eyebrows, nose, lips, and tongue. The navel, nipple, and genitals heal more slowly (eight to 38 weeks), since they are covered by clothing and exposed to friction from rubbing and moisture from sweating.⁷ Throughout the entire healing process, the pierced site should be cleansed daily and jewelry rotated to aid optimal healing times.¹⁵

The Living Canvas

Many cultures have practiced tattooing as a form of body art for centuries. For example, a recently discovered Bronze-age man had markings consistent with tattoos.¹³ Over the years, popularity of this form of body adornment has waxed and waned. In the eighteenth century, tattooing was popular with royalty and the upper classes of Europe.¹⁶

Tattooing became more prevalent in the US in the nineteenth century following the invention of the electric tattoo machine or gun.¹⁷ Tattoo parlors were concentrated in coastal cities and frequented by sailors on leave. More recently, Janis Joplin, a popular music star of the 1960s, sported tattoos, followed by successors, such as singers Tommy Lee and Cher, film stars Drew Barrymore and Sean Connery, and professional athletes Shaquille O’Neal and Dennis Rodman. Subsequently, tattooing has gained popularity among virtually all segments of society.

Tattooing has been used not only as a form of body art but also for cosmetic purposes. Some women seek facial tattooing as a method of permanent adornment that reduces the need for cosmetics. This can be helpful when musculoskeletal dysfunction or compromised vision impairs the ability to apply makeup.^18,19 Tattooing has also been used for people with alopecia who choose to have “eyebrows” tattooed on, or vitiligo who may attempt to camouflage their pigmentation disorder,²⁰ and also after breast surgery to recreate the nipples and areolae.²¹ An iron oxide pigment will be injected into the middle layer of the skin for a result that lasts significantly longer than the eyeliner in your bathroom drawer.²⁰

Tattooing is legal in all states, but as with the piercing industry, the training of tattoo artists, sterilization of instruments, and inspection of the studios depends on state laws.²² Tattoo artists consider themselves professionals, but mandatory licensure, registration, or permits are currently required in about 74% of the states.^11,22 Along with body piercing, regulation, certification, and legislation in all states should be implemented in the near future.¹¹ The Alliance for Professional Tattooists (APT) is a nonprofit organization to provide health and safety guidelines within the tattoo industry.²³ To provide the artists with current information, APT holds nationwide conventions regarding the prevention of disease transmission in tattooing. Upon completion of this seminar, a tattooist would fulfill state education requirements as well as conform to OSHA’s Bloodborne Pathogen Rule. All members must pass the seminar within two years of joining. The National Institute of Environmental Health Sciences recommends using APT-certified tattooists to ensure compliance with infection control guidelines.²³ Although the Food and Drug Administration has approved numerous color additives for use in superficial cosmetics, none have been approved for injection into the skin.²⁰ Using an unapproved color additive in tattoo ink creates an adulterated substance with an unknown purity and identity.^13,20

Tattooing consists of a series of repetitive punctures that deposit pigment into the dermis to a depth of approximately one to two millimeters with an electrically powered tattoo gun.¹⁸ Superficial bleeding along with plasma and tissue exudate occurs from the puncture sites. The tattooed skin becomes erythematous and exhibits dermal and subcutaneous edema.¹⁸ Superficial crusting occurs at the tattoo puncture sites. As the tattoo heals, superficial epidermal cells slough off, leaving the deeper basal epidermal cells.¹⁸ Newly tattooed skin is tender to palpation. Healing takes place in approximately seven to 10 days, and complete epidermal regeneration in about two weeks.¹⁸

Procedures used for tattooing vary with the experience of the tattooist. Amateurs may use needles or other makeshift items, such as pens, pencils, pins, paper clips, sewing needles, or kitchen utensils. Amateurs may inject materials such as India ink, carbon, charcoal, or mascara.^2,5 Adolescents, gang members, and people in prison often turn to amateurs for financial reasons or because they do not have access to professional artists. Tattoo kits, often advertised on the back of popular tattoo magazines, allow for untrained artists to practice on friends, and facilitate stands at flea markets and fly-by-night shops.²⁴ Home-done tattoos, done with a sewing needle and India ink, often end in customer dissatisfaction.²⁴ Unfortunately, amateurs typically do not have the access to sterilization equipment or the familiarity with aseptic technique that characterize the practices of many professional artists, so the risk of disease transmission and infection are greater.

Piercing is not considered permanent because the tracts, especially if small, may close after jewelry is left out for a period of time. On the other hand, tattoos can only be removed through costly and time-consuming processes. The most common procedure used to remove tattoos is with a laser; other methods include dermabrasion, chemical cauterants, and surgical resection.^18,25 The cost of tattoo removal can range from $350 to $2,500, depending on the color of the inks, the size of the tattoo, ink density, and whether an amateur or professional tackles the task.²⁶ Alternatively, some regretful customers may attempt to camouflage an objectionable tattoo with an acceptable one.²⁶

The Decision for Body Art

People decide to pierce their bodies for a variety of reasons, including cosmetic appearance, spiritual beliefs, and the enhancement of sexual pleasure.²⁷ Teenagers have their own reasons, such as making a personal statement or being daring or fashionable.⁸ Teens often follow such fads because of peer pressure and the need to fit into a group. Piercing is perceived as “temporary” when compared to having a tattoo,⁷ and teenagers may regard the decision as having few long-term consequences. But if adolescents are hesitant to go to a skilled piercer, they often pierce themselves or are pierced by an inexperienced friend.⁷ Years ago, young girls considered ear piercing as a right of passage. Many slumber parties often included extremely amateur piercing with simply mom’s sewing needles and ice cubes.²⁴

The motivation to acquire a tattoo varies among groups and cultures. Risks that are weighed can be classified around the purchase, such as cost or discomfort; possession, such as the reactions of family, friends, and employers; and health.^2,4,5 Some persons obtain tattoos as a means of asserting their personal identity or sexual orientation.^28,29 For example, the breasts and buttocks are very popular areas for tattoos for women. Tattoos may be a testament to feelings of love, such as having a significant other’s names or “mom” or “mother” inscribed on one’s body. Tattoos also have been associated with rites of passage and identification with groups, such as street gangs.³⁰ Some gang members also use tattoos to identify girlfriends as their property.¹ One researcher’s finding that women frequently acquire tattoos with a “purchase pal” emphasizes the social connection associated with tattoos.⁴

Not a Risk-Free Decision

Any break in the skin can expose a person to local infection as well as systemic illness. While infections may occur in persons receiving body piercing and tattoos, other complications are unique to the specific type of body adornment. Local infections present as redness, swelling, warmth, pain, and purulent drainage. Cellulitis may occur if an infection moves into the surrounding tissue. Signs of cellulitis include redness, firm cellulotic tissue, warmth, and pain. Local infection may invade the surrounding tissue and can become systemic, particularly if the tissue is not healing and the infection is not properly treated.³¹

Systemic infections can be introduced from either piercing or tattooing.^18,32,33,34 Exposure to contaminated needles or instruments can increase the risk of HIV, hepatitis, or tetanus. However, while the opportunity for infection is present, actual incidence rates are not known because they are not well documented in the literature or by the Centers for Disease Control and Prevention (CDC). A recent Hepatitis B outbreak in Toronto from electroencephalogram needles has been investigated and Health Canada has implemented infection control guidelines for practicing piercers.¹² The CDC has documented one case of HIV transmission from acupuncture and a case of endocarditis after a tongue piercing.^{35, 36} Also, the CDC HIV/AIDS prevention page recognizes tattooing and piercing as risks for HIV transmission if instruments are not sterilized or disinfected between clients.³⁷ In addition to infection, other localized problems from piercings include abscesses, scar formation, and complications in patient care situations. For example, healthcare providers may instruct patients with infected piercings to remove the jewelry; however, jewelry removal may allow healing and closure of the epidermis, while promoting abscess formation in deeper skin structures. Infections should be treated with topical or systemic antibiotics and the jewelry left in until the infection resolves.³⁸

Granulomas, nodules formed around a foreign body such as tattoo pigment or piercing jewelry, are issues in body art.²⁰ Keloid scars, a cosmetic problem, may form at the pierced site. A Prince Albert ring, commonly used in penile piercings, results in permanent openings through the urethra that permit additional outlets for urine and semen. Paraphimosis, a strangulation of the glans penis from foreskin retraction, may occur in penile piercings in uncircumcised men. The tip of the penis becomes swollen and tender as blood and fluid are trapped. To release the constriction, the foreskin is pulled down over the glans.³⁹ Electrical burns can occur if body jewelry is worn and exposure to a current occurs, such as electrocauterization. Defibrillation during cardiac arrest could result in burns if a nipple ring is present.

Other situations in which piercings may complicate patient care include: (a) trauma and bleeding, including motor vehicle accidents and contact sports; (b) emergency situations, such as aspiration of tongue or mouth jewelry; and (c) interference of piercings with intubation. Unless emergency staff members are attuned to the possibility of tongue piercing, it may go unnoticed and unnecessary blood loss will occur. If a piece of jewelry is aspirated, direct visualization with a laryngoscope and removal of the metal is necessary to clear the airway. An X-ray may be required to locate aspirated rings or studs if they cannot be visualized. If the jewelry is lodged into the tissue, removal may be desirable under conditions where emergency hemorrhage can be handled, such as the operating room. Any jewelry that is removed should be treated as contaminated with body fluid and placed in a container with antiseptic solution.⁴⁰

To remove jewelry, the bead must be detached. There are two types of bead closures — the captive bead ring and the bead screw. The captive bead ring is held closed by pressure; the hoop can be opened and pulled apart at the bead. The bead screw is common on hoops, barbells, and horseshoes; the bead is removed by turning it counterclockwise. After the bead is detached, the jewelry can be removed.

Problems specific to tattoos arise from the intradermal puncture procedure. Temporary puncture inflammation is a common localized response in people with new tattoos. Later complications can include impetigo, furunculosis, cellulitis, keloids, and lymphadenopathy.^18,32,41

Individuals may experience sensitivity to substances used in tattoo pigments, such as mercury, chromium, cadmium, and cobalt.¹⁸ Localized symptoms of edema, erythema, and pruritus may occur when sensitivity is present. Severe reactions may necessitate removal of the tattoo,¹⁸ which may become particularly problematic because of the extensive removal process and time required for all pigment to be excavated.²⁰ Henna tattoos, an alternative to permanent tattoos lasting approximately six weeks, adorn many adolescent bodies.²³ Made with Indian henna dye, one specific form of the ink, labeled “black henna” and made of a toxic hair dye, can cause an allergic reaction as well.²³ Tattoos have been reported to alter the quality of magnetic resonance imaging (MRI) when the pigments are iron oxide based. Mascara produces a similar effect; however, this product is easily removable.²⁰ Furthermore, interaction of the MRI with molecules in the tattoo pigments has been noted to cause sudden burning pain during the procedure.⁴²

A visit to the tattoo parlor allows the customer to ask questions about sterilization and disposal practices. Are pigments used for tattoos dispensed from single use containers? Are disposable, sterile needles used for each tattoo? Is other equipment sterilized after each use? Does the professional tattooer wear disposable latex gloves for each customer and re-glove after leaving the area during the procedure?⁴³ If the answer to each of these questions is “yes,” basic aseptic procedure is in place.

Aftercare

Tattooers and piercers may recommend a variety of aftercare instructions. Because these instructions are not standardized, it is important that they are based on general antimicrobial principles.

Aftercare for piercing depends on the site. Tongue piercing results in some swelling for several days afterward, which can be minimized by sucking ice cubes. Rinsing with salt water or mild mouthwash can also help. Liquids and soft foods are the easiest to tolerate until the swelling subsides. Any trauma to the tongue should be avoided, including French kissing and oral sex.²⁷ Lip piercings are kept clean with soap and water.

Genital piercings should be cleansed with warm salt water to prevent discharge from accumulating around the site. All sexual activity should be avoided for at least two weeks while the piercing heals. A condom should be worn for at least eight weeks to avoid the risk of infection. If condoms are worn, it is wise to wear two in order to avoid tears through which organisms can travel.

Navel piercings can take from four to nine months to heal because the area is subjected to friction from clothing.⁴⁴ Dampness from perspiration may prolong the healing process. Tight clothing should be avoided until the area is healed. The pierced site should be cleansed daily with antibiotic soap and water, and the soap must be rinsed off well to avoid skin irritation. Rotating the jewelry through the site during washing may help the cleansing process.¹⁵ Nipple piercings usually heal within six to eight weeks.⁴³ Wearing a bra depends on personal preference; some find that it protects the pierced site from friction and rubbing, while others prefer to be braless while the piercing heals.

Some tattoo artists suggest covering the new tattoo with a sterile dressing or plastic wrap to keep the area moist. After 24 hours, the tattooed skin should remain open to air.¹⁸ The tattoo site can be cleansed with a mild soap and water to remove exudate. A mild lotion and cream may be applied to keep the skin supple. Application of alcohol-based products, which are irritating and drying to the skin, should be avoided. The site should be protected from direct sunlight to avoid sunburn until the area is healed.

Nursing Considerations

Nurses who are familiar with current practices, decision-making, health risks, and aftercare will be able to provide the most appropriate care to this population. Nursing activities arising from the contemporary body art renaissance include counseling, assessment, and advocacy.

Open, honest communication is based on knowledge and a nonjudgmental attitude toward the individual who seeks care. A base of sound information will influence the best decision and outcomes. Health risks are best presented as part of an overall information package. A pamphlet or handout can be taken home and kept as a reference can guide decision-making. If materials about body adornment are present in the waiting room of an office or student health service, it sends a message to clients that this is a safe topic for discussion. Content of patient education materials can include choosing an artist or studio with a good reputation, talking to the staff about the procedure and safety guidelines followed, and learning as much as possible before piercing or tattooing.⁴⁰

With new piercings and tattoos, nursing care focuses on assessing the area for healing and the presence of untoward effects. Nurses can promote healthy teaching about disease transmission and complications associated with body art. In the past several years many new resources for patient education have appeared on the Internet. Many of these sites include pictures of normal and abnormal piercings, which can be useful for both patients and healthcare providers who want to be up to date in their awareness of body art. The Association of Professional Piercers focuses on public information as well as technical data for piercers. Their website is extremely user friendly and has a frequently asked questions section that addresses many topics related to health.¹¹ Patient education pamphlets focusing on body art are also available from health education companies. Printed pamphlets have been shown to increase patient knowledge, but another benefit is that clinicians who provide pamphlets and posters about health-related topics in their waiting rooms send a message that they are willing to engage in conversations with their clients on those subjects.⁴⁵

Nurses are in key positions to educate the public about the health and safety issues surrounding body art. For example, by talking to student groups about body art, health concerns can be addressed along with current information about piercing and tattooing. Students in middle school, high school, and college are interested in body art; some want information to help them decide if they want a piercing or tattoo, and others are curious about body art in general. If students identify body art with a knowledgeable nurse, they may consider health implications in their decision. These students will also expect nurses to be informed and understanding providers when they have questions or concerns about body art. Nurses who visit classrooms can also form relations with school nurses who are primary contacts for many student health issues.

Another venue for impacting health issues of body art is legislative efforts to regulate piercing and tattooing practice. Regulation that ensures minimum safety standards will protect the health of consumers who desire tattoos or piercings. Influence aimed at state and local regulators can result in fewer complications from these procedures. Forming a cooperative relationship with tattoo or piercing establishments for the purpose of consulting on safety and hygiene issues is one method to reach the practitioners of body art. Partnerships with body artists are key to gaining expertise and influence in this arena.

Body art health issues are phenomena that could be researched from multiple perspectives. Nursing research could contribute knowledge about why body art is popular among various segments of culture, why certain tattoos and piercings are chosen, what best practices for healing are, how complications should be treated, and how education affects body art practices.

Finally, other healthcare providers need to become aware of body adornment and its implications for teaching, counseling, and treating individuals in a variety of settings. Educational presentations at professional conferences, community talks, and informational sessions at practice sites are methods to increase understanding about body art to health care providers. For example, an author of this article (M. Christensen) has consulted with several hospital operating room staffs regarding policies and procedures related to piercings in the operating room. Nurses, physicians, and other healthcare workers who are savvy about these issues will get the point — body adornment is a healthcare issue.