Infectious Complications of Body Piercing S. Samantha M. Tweeten and Leland S. Rickman From the University of California, San Diego (UCSD)/San Diego StateUniversity Joint Doctoral Program in Public Health (Epidemiology) andthe Division of Infectious Disease, Department of Medicine, UCSDSchool of Medicine, San Diego, CaliforniaBody piercing appears to be gaining in popularity and social acceptance. With the increase in the number of piercings, it is likely that health care providers may see an increase in the complica- tions resulting from these piercings. These may include the transmission of hepatitis viruses and bacteria at the time of the piercing or in the course of wound care. We review the infectious complications that have resulted from body piercing and have been documented in the medical literature.
Body piercing, the use of needles, rings, steel posts, or other
a penile piercing, subsequently named for him (and purported
adornments that penetrate the skin and other structures of the
to be a common practice among the well-dressed men of
human body, predates history. Piercing appears to be increasing
London at the time). Its purpose was said to be to hold the
in popularity and, as discussed in a prior review of the infec-
penis tightly against the thigh so that the stylish tight trousers
tious complications of tattooing , may increase the risk of
would fit better . In Europe and North America, body
various complications. The medical literature on postpiercing
piercing has been seen by those in ‘‘punk’’ and antiestablish-
infections occurring in areas other than the ear is limited, and
ment subcultures as symbolic of deviance and rebellion, par-
there are few reliable data on incidence or prevalence. Most
ticularly when tattooing was discarded as being too main-
publications are case reports. It is probable, however, that prac-
titioners will see an increase in infections in a variety of pierced
Apparently gaining in popularity, body piercing also appears
body sites. We review the infectious complications of body
to be gaining limited social acceptance. The ear is still the
piercing that have been documented in the medical literature,
most common body piercing site. However, other facial sites,
in an effort to increase clinicians’ awareness of potential prob-
including the eyebrow, lip, nose, and tongue, as well as the
hidden sites of nipples, navel, and genital areas of both sexes,are being pierced with increasing frequency . Owing in partto the more intimate nature of some piercings, there are no
See article on related topic on pages 767 – 8.
reliable statistics or demographic data available about the peo-ple being pierced. One survey indicates that £80% of Ameri-can women have pierced ears . Infections seen in ear sites
Background and Demographics of Body Piercing
may thus reflect potential infectious complications associatedwith other piercing sites.
Until recently in this century, body piercing at sites other
People pierce their bodies for a variety of reasons. The
than the earlobe has been relatively rare in western culture.
counterculture youth are thought to be more inclined toward
However, there is a long history of body decoration by piercing
facial piercings that may provide increased shock value as
the skin. Such piercings have been done as a rite of passage
they are seen by others . Although genital piercings have
or to indicate marriageability or social standing . Roman
anecdotally been seen primarily in homosexual men, hetero-
centurions were said to have pierced their nipples to hold their
sexuals (both male and female) are getting pierced in increas-
capes and as a sign of loyalty to the Emperor . Mayans
ing numbers for both sexual and aesthetic reasons . Sado-
pierced their tongues for spiritual purposes . The Pharaohs
masochism has also been implicated in the recent increase
of Egypt ceremoniously had their navels pierced .
in interest in body piercing , but many more people are
Genital piercings were, and still are, seen in areas around
being pierced for other reasons . It may be done to in-
the Indian Ocean and among peoples of the South Pacific [3,
crease self-esteem. Young women in particular may be
4]. Prince Albert, consort to Queen Victoria, was said to have
pierced at times when they feel they have lost control of theirlives .
Body piercing is perceived by some as a form of deviant
Received 9 June 1997; revised 5 November 1997.
behavior that may lead to other risks. Fiumara and Eisen 
Reprints or correspondence: Dr. Leland S. Rickman, UCSD Medical Center –
stated that those with ‘‘exotic’’ piercings, primarily genital,
8951, 200 West Arbor Drive, San Diego, California 92103-8951.
were at high risk for sexually transmitted diseases. Their pa-
Clinical Infectious Diseases 1998; 26:735 – 40
tients with these genital piercings appeared to be primarily
᭧ 1998 by The University of Chicago. All rights reserved. 1058–4838/98/2603 – 0028$03.00
homosexual men. Analysis of a sample of 20 high-school stu-
dents who had been pierced at a variety of sites including
The jewelry is selected with the type of piercing in mind.
the tongue and navel, however, found that the students were
The type of piercing, location on the body, and client needs
generally academically solid and had good attendance .
determine the gauge of the jewelry and the diameter of the
People of all ages and professions are appearing in piercing
rings or length of the ‘‘barbell’’ to be placed. Once the jewelry
studios, requesting jewelry placement at all sites.
is chosen, a single-use, nonreusable setup should be used toperform the piercing. Any items that are not disposable mustbe autoclaved between clients, as should the jewelry to be
Body Piercing Methods
placed. Single-use items such as needles and corks must be
Regardless of the site of a piercing, aseptic techniques should
packaged in individual sterile packaging. A piercer should wear
always be used to reduce the risk of infection. Aftercare, the
examination gloves, changing them between clients or anytime
care of the piercing site after introduction of jewelry, is also
contamination may have occurred .
of importance in preventing infection and must be meticulously
Once the client is ready and has been placed on a flat surface,
performed. Antibiotic prophylaxis, however, is not generally
the piercer should cleanse the area to be pierced with a topical
required for the prevention of bacterial endocarditis .
antiseptic. The site is marked to provide a guide for the needle
The most common piercing site is the earlobe. This is often
and is grasped with a Pennington forceps. A large-gauge (12 –
pierced with a spring-loaded ‘‘gun,’’ which punctures the lobe
16-gauge) hollow needle is inserted quickly, and a cork is
with a sharp metal stud. This effectively tears a hole through
placed on the sharp end. The jewelry is brought through the
the tissue. A backing is placed on the earring stud to hold it
hole, following the needle in a needle-and-thread fashion, and
in place. Recently, the piercing guns themselves have been
is sealed with a bead, metal ball, or disk .
recognized as a possible vehicle for the transmission of viral
The client is instructed not to touch the piercing until it is
hepatitis. The guns are not easily cleaned and are infrequently
healed, is taught how to cleanse daily, and is made aware of
sterilized. The transmission of hepatitis B virus (HBV) has also
the signs of infection and the chances of injury. Variations on
been associated with spring-loaded finger-stick devices, which
these procedures may occur. In piercing of the tongue, a longer
have a similar mechanism of action to the piercing gun and
‘‘barbell’’ is usually initially placed to allow for edema of the
may be inappropriately cleaned [13, 15].
tongue . It is then replaced, if desired, with a shorter rod.
The gun method is used frequently by physicians as well as
The client is instructed to use an antiseptic mouthwash several
at department and jewelry stores. Ear piercing is also often
done by friends or relatives with various household needles,
Generally, local anesthesia is not used for body piercing. In
sometimes with thread in the hole, or with jewelry. The piercing
the Prince Albert penile piercing, the needle goes through the
gun is designed for piercing earlobes only, as it is not adjustable
urethra. A topical anesthetic may be applied and a needle-
to deal with varying thicknesses of other tissues, and em-
receiving tube used to guide the needle and to minimize tissue
bedment of the earring backs is more likely to occur if the gun
damage because of the increased potential for pain during the
Body piercing is not always performed with an aseptic tech-
Piercings done with an ear-piercing gun also require site
nique. Some people choose to pierce themselves. This is rarely
preparation. Generally, a topical antiseptic is applied to the
functional, as the piercing must be done at sufficient depth to
earlobe and the position of the piercing is marked on the lobe.
keep the jewelry in place. Too-shallow insertion may lead to
A metal piercing stud with a sharpened end is placed in the
rejection of the jewelry or an increased chance of injury. The
gun and applied to the lobe, and the spring trigger is released
choice of jewelry is also important. Surgical steel (300-grade),
to drive the stud through the lobe, tearing through the tissue
niobium, or gold is usually used, although contact dermatitis
rather than creating a hollow tube through which the ring is
may occur with surgical steel or gold . Use of jewelry con-
placed. The earring must be sterile and the piercing gun appro-
taining other metals may lead to dermatitis or metal sensitiza-
priately cleaned and sterilized to avoid infection. Aftercare is
as important in ear piercing as it is in other piercings.
The jewelry most commonly inserted at piercing sites other
Healing times for piercing vary according to placement.
than the ear consists of a barbell-shaped ornament, bent or
Those areas that are exposed — ears, lips, eyebrows, and
straight; a ring with a bead; a stud with a metal ball at one
tongue — tend to heal quickly; the tongue heals in 3 – 6 weeks
end and a flat disk on the other for the labret (a piercing through
and the others in 6 – 8 weeks. Nipple piercing is more variable
the area below the lower lip); or in the case of some septum
and is said to be dependent on the type of clothing worn.
piercings, a tusk . Inert plastics may also be placed after
Such healing can take 8 – 16 weeks . The wearing of tighter
clothing is generally reported to inhibit healing. Navel piercings
A reputable piercer should follow a protocol for all piercings
may take up to 9 months to heal, reportedly in part because
and adhere to safety guidelines . The protocol follows asep-
they are frequently covered by tight clothing such as jeans and
tic surgical technique . It begins with thorough instruction
pantyhose . Genital piercings are reported to take less time
of the client about the procedure, risk, consent, and aftercare.
Infectious Complications of Body Piercing
Complications of Piercing S. aureus after their ear piercings became red and inflamed. The first, a 15-year-old girl, and the second, a 14-year-old girl,
experienced redness and swelling of the earlobe, and eventually
Many noninfectious complications of piercing have been
the diagnosis of hematogenous osteomyelitis of the iliac crest
reported. In ear piercing, metal-allergic dermatitis may result
was established. The third patient was a 2-week-old girl whose
[21 – 25]. Use of the ear-piercing gun can result in earrings
ears were pierced 2 days prior to admission to the hospital for
being deeply embedded in the lobe [16, 26, 27], which may
fever. Her blood and CSF cultures subsequently yielded
be mistaken for keloids [28, 29]. Inflammation may become
so extreme as to envelop the piercing jewelry . Keloid
S. aureus was also isolated from the external ear discharge
formation may occur as a late complication of body piercing
of a 5 1/2-week-old girl shortly after her ears were pierced .
[31 – 36]. Pseudolymphoma or lymphadenopathy may also oc-
She was admitted to the hospital because of abdominal disten-
cur with any piercing [37, 38], and sarcoidal tissue reaction
tion and loose stools. McCarthy and Peoples  described a
6-year-old child with chronic neutropenia who developed toxic
Torn ear lobes and other trauma are not uncommon among
shock syndrome shortly after having her ears pierced. The
those with pierced ears [32, 40, 41], but injuries to other areas
discharge from the inflamed earlobe was found to contain toxin-
do occur. Rings in nipples may be torn out. Higgins et al. 
producing S. aureus. Piercings traversing the auricular cartilage
reported a patient with urethral rupture following avulsion of
may also produce infection, particularly if a piercing gun is
a Prince Albert ring. Wilcox  expresses concern that penile
used. This was the case for a 14-year-old girl whose ear re-
piercings may increase the chance of tissue destruction in the
quired incision and drainage (I&D) . Cultures of the drained
sexual partners of those with piercings.
material yielded Staphylococcus species and Pseudomonas aer-
Body jewelry may become an issue in radiology, as it may
appear as a peculiar artifact if the patient is unwilling or unable
P. aeruginosa has also been reported to occur in others when
to remove it . Reichle and Dailey  point to the potential
ear piercings involve the auricular cartilage. Turkeltaub and
for airway obstruction due to the edema associated with tongue
Habal  reported a case of acute chondritis following ear
piercing. Price and Lewis also express concern about problems
piercing. A 16-year-old girl required I&D for an abscess that
with piercings in oral sites, including airway obstruction, chipped
had failed to respond to cefadroxil after her ear piercing. She
or cracked teeth, and interference with mastication .
had initially sought treatment for erythema, swelling, and ten-derness at the site of the piercing. A 45-year-old Italian womanfound that her ear became swollen and tender following place-
ment of an acupuncture staple, similar to an earring, in the
Infections following piercing have been reported infre-
pinna for weight loss . Green discharge was seen and
quently in the medical literature. Cortese and Dickey  found
P. aeruginosa was isolated in culture. The patient required
that 11% in a survey of student nurses with pierced ears had
surgical I&D and was left with some deformity. A 13-year-old
infection with purulent discharge. Biggar and Haughie 
also required I&D after developing infection of the high exter-
found that 24% had infection with purulent discharge. An or-
ganism may be introduced to the piercing site at two points in
P. aeruginosa infections of the ear have been reported to
time. The first is when the piercing is done with poor technique
require substantial resection of necrotic tissue. This was the
and unsterile instruments. The second is during the aftercare
case in a 20-year-old woman presenting to an emergency de-
of the piercing site, when the wound is not kept clean or is
partment 2 weeks after undergoing a piercing through the auri-
cle . She had pain and discharge, which were treated empir-
Some bacterial infections, like those reported by Scully and
ically with oral dicloxacillin. When she returned several days
Chen  of pierced tongues requiring the expression of puru-
later with no change in her symptoms, I&D was performed
lent material, will spontaneously heal. A nipple piercing that
with removal of necrotic tissue, which resulted in cosmetic
resulted in an abscess of the left breast was reported by Fiumara
deformity. Irrigation and debridement, with administration of
and Capek . The abscess responded to ampicillin therapy.
intravenous ceftazidime and ciprofloxacin, cleared the infec-
Some infections have required surgical irrigation and debride-
tion. Cumberworth and Hogarth  reported P. aeruginosa
ment. With treatment, most bacterial infections will heal, but
infection in a woman who presented with pain and a large
because of the intimate nature of some piercings, or because
abscess after her upper ear was pierced with an ear-piercing
of fear, some patients will not seek timely medical advice.
gun. She required resection of a large portion of the upper ear. Staphylococcus aureus is the organism most often reported
Also reported with some frequency and sometimes leading
with regard to infected piercings. It was the predominant organ-
to life-threatening outcomes after body piercing are infections
ism recovered from a group of girls who had held a ‘‘piercing
due to group A b-hemolytic streptococci (GABHS). Jay 
party’’ in a children’s home . Lovejoy and Smith 
reported infection with GABHS in a series of children seen in
described three patients whose blood cultures were positive for
a clinic. A 17-year-old boy was seen following an ear piercing
that resulted in a cutaneous infection at the piercing site. This
reported in the medical literature beyond a few case reports
led to septic arthritis and acute glomerulonephritis . Culture
about non-ear sites, it is probable that health care providers
of a joint aspirate and discharge from the ear yielded GABHS.
will be called on to treat complications resulting from the
George and White  reported a woman who attempted to
practice. Piercings may also be of concern for emergency ser-
repierce an infected ear lobe. She became toxic and presented
vices personnel, as the jewelry may cause obstruction or be
in shock. Blood cultures were positive for GABHS, and the
patient developed bronchopneumonia and acute renal failure.
Patients may be reluctant to seek medical care because of
After a protracted hospital course and a long convalescence,
the potential for embarrassment about a piercing. The health
care provider should obtain a history of piercing, particularly
Erysipelas has been reported after ear piercing . Also
when presented with unexplained hepatitis, endocarditis, or
reported with infection due to GABHS is endocarditis; a nose
other syndromes for which piercing may be a risk. To be most
piercing resulted in endocarditis in one young woman , and
effective, this must be done in a nonjudgmental fashion. No
a 15-year-old boy developed a ventricular septal defect from
patient wants to be made to feel a deviate or unacceptable
endocarditis that followed an ear piercing .
for having a nonmainstream body piercing, particularly when
Other bacteria have the potential to be inoculated at piercing
sites. Primary tuberculosis was inoculated into the earlobe of
Several cases in this review required second hospital admis-
an 18-month-old child by a mother with active pulmonary
sions because of failure of antibiotic therapy. These complica-
tuberculosis . The child’s tuberculosis was localized to the
tions may be minimized by culturing specimens from the in-
area around the ear and neck. Ear piercing has been reported
fected site for organism identification and determination of
as a method of inoculation of Clostridium tetani in India and
appropriate antibiotic therapy. Removal of the jewelry, acting
Senegal . Thorner cites cases of death due to tetanus follow-
as a foreign body, may be required to cure local infection.
Body piercing will continue, so prevention of infection must
Viruses may also be inoculated in the course of piercing.
be of concern. Many bacterial infections have been shown to
Transmission of HBV has been well documented in cases in
occur following piercing, and the risk of hepatitis B and C has
which needles and other equipment have been shared in body
been associated with piercing. Although no cases have been
piercing as well as tattooing [1, 66] and in association with
reported in the medical literature, it is possible that HIV may
finger-stick devices and acupuncture [13, 15, 67]. In a large
also be transmitted through unsterile, shared piercing tools [79 –
retrospective Italian study , ear piercing was significantly
81]. Transmission of HIV has been shown to occur with acu-
associated with hepatitis, even when intravenous drug use and
puncture treatments . Of concern is the lack of regulation
multiple sex partners were controlled for (OR Å 2.20; 95%
of those who perform body piercings and the facilities they
CI, 1.51 – 3.22). A case-control study in the state of Washington
found that those having HBV were significantly more likely
Several states have enacted legislation to regulate both tat-
(P õ .001) to have had their ears pierced than controls .
tooing and body piercing. A bill (AB186) is pending in Califor-
Karim et al.  found that HBV seropositivity in females was
nia that would require practitioners of tattooing and body pierc-
significantly associated with ear piercing (P õ .001) among
ing and those applying permanent cosmetics to be registered
black urban children in South Africa.
with the county in which they practice.
Van Sciver  reported a patient with hepatitis in whom
Those in these businesses would have to comply with mini-
the only identifiable risk factor was having had her ears pierced
mum health and safety guidelines, pay licensing fees, and sub-
3 months prior to development of symptoms. A patient with
mit to inspections and fines by county health departments. It
acute HBV seen at Massachusetts General Hospital (Boston)
is hoped that regulation will reduce the potential for infectious
was thought to have been exposed to the virus through ear
complications of body piercing and tattooing. The Association
piercing . This case resulted in severe hepatic necrosis
of Professional Piercers  supports the standardization in
and death after a long hospital course. Another case of HBV
safety and piercing practices. Piercings done with a maximum
infection, reported by Parry , followed ear piercing; no
of care will reduce the number of infectious complications that
other risk factors were identified, and the infection resulted in
Body piercing  and tattooing  have been demon-
strated to be risk factors for the acquisition of hepatitis C virus,
as have acupuncture  and injection with nondisposable nee-
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OSPAR CONVENTION FOR THE PROTECTION OF THE MARINE ENVIRONMENT OF THE NORTH-EAST ATLANTIC OSPAR List of Chemicals for Priority Action (Up-date 2002) OSPAR List of Chemicals for Priority Action (Up-date 2002) Type Group of substances / substances EINECS No Identified at †: Lead country: Background document A: CHEMICALS WHERE A BACKGROUND DOCUMENT HAS BEEN OR IS BEI
FW-P200 INTRODUCTION The FW-P200 has unique Alarm Power Saver The FW-P200 is an advanced, fully supervised (APS) mechanism that enables transmitter low-current wireless PIR that includes a FreeWave activation only 2 min after the last movement has FREEWAVE™ WIRELESS PIR transmitter. Both transmitter and detector circuits are powered by long life Lith