Health Risks Associated with Tattoos and Body Piercing
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Clinical Review
Health Risks Associated with Tattoos and
Body Piercing
Susannah Grimm Poe, EdD, BCBA–D, and Anne Cronin, PhD, OTR/L
ABSTRACT so well accepted that most studies of body piercing do
• Objective: To review the health risks associated with not include earlobe piercing [5].
tattoos and body piercing. There are important physical and behavioral risks
• Methods: Review of the literature. associated with body modification. In this paper, we
• Results: Tattooing and piercing have become increas- review the epidemiology, potential complications, and
ingly popular practices in the United States. There behavioral factors associated with tattoos and piercings.
are important physical and behavioral risks associ-
ated with these forms of body modification. The most Epidemiology
common complications from tattooing include skin Tattoos are increasingly popular, with a 2012 Harris poll
infections and allergic reactions. Minor complications indicating that 1 in 5 adults has at least 1 tattoo [6], up
such as infection and bleeding occur frequently with from 14% in 2008 [7]. In the 2012 poll, adults aged 30
piercings, but major complications have also been to 39 are most likely to have a tattoo (38%) compared
reported. Tattoos and piercings appear to be a marker to both those younger (30% of those 25–29 and 22%
for risk-taking behavior. of those 18–24) and older (27% of those 40–49, 11% of
• Conclusion: Clinicians should understand the poten- those 50–64 and just 5% of those 65 and older). Women
tial complications of these procedures and be able to are slightly more likely than men, for the first time since
counsel patients on how to reduce their health risks. this question was first asked, to have a tattoo (23% versus
19% in men). Current US body piercing rates are approx-
T
attoos and piercings are ancient practices of body imately 36% [3]. Body piercing is more popular among
modification that have gained widespread ac- women than in men [8]. Among adolescents, body pierc-
ceptance in modern society, particularly among ing is performed considerably earlier than tattooing [9].
young adults. Tattoos involve the insertion of colored The head area is the favored location for piercing, while
pigment into the dermal layer of the skin with the goal the most common location for a tattoo is the limb [10].
of creating a permanent marking. They are commonly
applied using an electrically powered handheld tattoo Associated Health Risks
machine that moves a needle up and down to inject ink Tattoos
through the epidermis and deposit a drop of ink into the The most common complications that result from tattoo-
dermis [1]. The cells of the dermis are more stable com- ing are skin infections and allergic reactions to the tattoo
pared with those of the epidermis, so the ink will mostly ink. Extensive skin puncturing can result in bleeding
stay in place for a person’s lifetime [2]. and prolonged leaking of serosanguinous fluid. Pyoder-
Body piercing is defined as the insertion of a needle mal infections can include temporary inflammation at
or specially designed piercing gun to create a fistula-like the site of needle puncture, superficial infections such
opening into either cartilage or skin for the introduc- as impetigo and ecthyma, and deeper infections such
tion of decorative ornaments [3]. These ornaments can as cellulitis, erysipelas, and furunculosis [11]. Unsterile
include jewelry, plastic or wood plugs, beads, or pearls. equipment and needles can transmit infectious diseases
Body piercing has been part of ritualistic or cultural
practices for centuries but is rapidly becoming a world-
wide mainstream fashion trend, especially among young From the West Virginia University School of Medicine,
women aged 17 to 25 years [4]. Ear piercing has become Morgantown, WV.
www.jcomjournal.com Vol. 21, No. 7 July 2014 JCOM 315health risks of body art
such as hepatitis [2]. Human immunodeficiency virus resonance imaging (MRI) exams. The metallic ferric acid
is theoretically transmissible this way, but no cases of pigments used in tattoos can conduct heat on the skin
HIV infection caused by tattooing have been docu- during MRI, resulting in traumatic burns [19]. This has
mented [12]. also been reported to occur with tattoos with nonferrous
Skin reactions to tattooing include aseptic inflam- pigments. In some cases, tattoo pigments can interfere
mation and acquired sensitivity to tattoo ink, especially with the quality of the image, such as when a person with
red ink, but also to chromium in green ink, cadmium in permanent eyeliner has an MRI of the eye [19].
yellow ink, and cobalt in blue ink [13]. The reaction can Patients may self-administer tattoos using sewing
manifest as either allergic contact dermatitis or photo- needles, forks, paper clips, or pens, and colorants may
allergic dermatitis. Cutaneous conditions that localize in include charcoal, soot, mascara, or ink. The use of unpro-
tattooed areas include vaccinia, verruca vulgaris, herpes fessional tattooists and piercers, who often have limited
simplex, herpes zoster, psoriasis, lichen planus, keratosis knowledge of health and hygiene precautions, is more
follicularis (Darier disease), chronic discoid lupus erythe- likely to lead to complications [10].
matosus, and keratoacanthoma. Other possible but less
common conditions include keloid, sarcoidal granuloma, Piercings
erythema multiforme, localized scleroderma, and lymph- While most body piercings are not problematic, the
adenopathy [12]. potential for localized infections as well as associated
A recent outbreak of nontuburculous nycobacterial systemic disease is present as long as the piercing site
infection was linked to contaminated tattoo inks [14]. remains open [20]. Bacterial skin infections at or near
Contamination can occur during the manufacturing pro- the site are the most commonly reported complication
cess due to use of contaminated ingredients or when inks of body piercings, with causative organisms primarily
are diluted with nonsterile water by tattoo artists [15]. consisting of Staphylococcus, group A beta-hemolytic
Investigations of 22 cases of tattoo-associated NTM skin Streptococcus, and Pseudomonas [21]. Contributing to
infections in 4 states that occurred during 2011–2012 the health risks of piercing is the reluctance of patients
found that ink was contaminated with NTM before use to seek qualified medical intervention when initial site
[16]. M. chelonae, one of several disease-causing NTM irritation, pain, or oozing occurs [21].
species, can cause lung disease, joint infection, eye prob- Systemic infections have been reported. More than 25
lems and other organ infections. These infections can be infective endocarditis cases in the past decade have come
difficult to diagnose and can require treatment lasting 6 from tongue, navel, earlobe, lower lip, and nipple piercings
months or more [15]. [21]. Infective endocarditis should be considered in indi-
Tattoo laws and regulations vary by state. The inks viduals with a new piercing (ie, up to 4 months), with or
and ink colorings (pigments) used for tattoos are subject without a history of congenital heart disease, who present
to regulation by the US Food and Drug Administration with unexplained fever, night chills, weakness, myalgia,
as cosmetics and color additives. However, the FDA has arthralgia, lethargy, or malaise [22]. General complica-
not traditionally enforced its authority over tattoo inks. tions include allergic contact dermatitis (eg, from nickel
The FDA encourages reporting of tattoo-associated or latex), bleeding, scarring and keloid formation, nerve
complications to its MedWatch program (www.fda.gov/ damage, and interference with medical procedures such as
Safety/MedWatch/). intubation and blood/organ donation [20].
Malignancies reported to develop within tattoos Oral piercings may lead to difficulty speaking and
include squamous cell carcinoma, basal cell carcinoma, eating, excessive salivation, and dental problems. Oral
malignant melanoma, leiomyosarcoma, and dermato- and nasal piercings may be aspirated or become em-
fibrosarcoma protuberans [17,18]. These malignancies bedded, requiring surgical removal. Tongue piercing,
may be coincidental, but carcinogenicity of the tattoo is usually performed without anesthesia, may cause dam-
as yet unknown. Another concern is that a malignancy age to teeth and gums, including dental fractures [23]
within a tattoo is more difficult to identify on skin ex- and changes in chewing and speech. Because of the
amination [11,17]. tongue’s vascular nature, prolonged bleeding can result
Rarely, tattoos or permanent makeup might cause if vessels are punctured during the piercing procedure.
swelling or burning in the affected areas during magnetic In addition, the technique for inserting tongue jewelry
316 JCOM July 2014 Vol. 21, No. 7 www.jcomjournal.comClinical Review
Table 1. Potential Complications of Body Piercings
Piercing Site Potential Complications
Ear Allergic reaction, auricular perichondritis, embedded earrings, infection, keloid formation, perichondral
abscess, traumatic tear
Genitals (women) Allergic reaction, compromise of barrier contraceptives, infection, keloid formation
Genitals (men) Frictional irritation, infection, paraphimosis, penile engorgement, priapism, recurrent condyloma, urethral
rupture, urethral stricture, urinary flow interruption
Mouth Airway compromise, altered eating habits, gingival trauma, hematoma formation, increased salivary flow,
infection, injury to salivary glands, interference with radiographs, loss of taste, Ludwig’s angina, pain,
permanent numbness, speech impediments, tooth fracture or chipping, uncontrolled drooling
Navel *
Bacterial endocarditis, frictional irritation, infection, jewelry migration and rejection
Nipples *
Abscess formation, bacterial endocarditis, breastfeeding impairment, infection
Nose Infection, jewelry swallowing or aspiration, perichondritis and necrosis of nasal wall, septal hematoma
formation
Reprinted from reference 38.
*In patients with moderate- to high-risk cardiac conditions.
may abrade or fracture anterior dentition, and digital versus those with 4 or more (Table 2), and among those
manipulation of the jewelry can significantly increase the with just 1 to 3 piercing versus those with 7 or more.
potential for infection [24]. In fact, complications arising Respondents with intimate piercings reported deviance
from oral piercing are so numerous—and in some cases levels similar to the heavily tattooed [26].
life-threatening—that the American Dental Asso- Several studies have found that those with body modi-
ciation has issued a formal statement opposing the fications engaged in earlier or more frequent sexual activ-
practice [24]. ity and had a greater number of sexual partners [26–28].
Other site-specific complications have been reported A study by Deschesnes and colleagues [29] reported that
(Table 1). Piercing tracts in the ear, nipple, and navel certain “externalized” risk behaviors were more com-
are prone to tearing [20]. Galactorrhea may be caused monly associated with tattooed and pierced youth than
by stimulation from a nipple piercing. Genital pierc- with their unmodified counterparts, including the use
ings may lead to infertility secondary to infection, and of drugs, gang affiliation, school truancy, and problem
obstruction of the urethra secondary to scar formation. gambling. Other studies of high school youth have found
In men, priapism and fistula formation may occur. Navel that tattooing was significantly and independently associ-
piercings account for 40% of complications arising from ated with other high-risk behaviors, including sexual in-
body piercing and are commonly associated with infec- tercourse, binge drinking, smoking, marijuana use, gang
tion and scarring. The peri-umbilical area is a popular membership, truancy, and school failure [30]. However,
site for self-piercing and a modern fashion statement, a survey of college students found that, compared to in-
but friction from clothing in this area may account for dividuals with no body art, individuals with 1 tattoo and
higher infection rates, longer healing time and increased less than 4 piercings had no greater likelihood to engage
scarring [25]. in high-risk behaviors [31].
Conversely, some researchers have attempted to show
Behavioral Risk a positive association for body modification. In a study
While the presence of tattoos or piercings is not neces- of women with eating disorders, the authors sug-
sarily indicative of any aberrant patterns of behavior, gested that body piercing could be seen as reflecting
clinicians should consider not only medical but also a positive attitude towards the body, an expression of
behavioral risks when tattoo or piercing is evident in self-care [32]. In addition, people with piercings are
patients, especially if that body modification is extreme. more likely to give attention to their physical appearance
Koch et al [26] report stark differences in the levels of de- and are less likely to be overweight than people without
viant behavior among college students with just 1 tattoo piercings [33].
www.jcomjournal.com Vol. 21, No. 7 July 2014 JCOM 317health risks of body art
Table 2. Tattoos and Deviance: Comparative Percentages and Chi-Square Analysis
Variable No Tattoos 1 Tattoo 2–3 Tattoos 4+ Tattoos P Value
Cheat on college work
Once/year or less 81.6 (n = 1217) 82.0 (n = 123) 83.1 (n = 59) 76.5 (n = 13)
Once/semester or more 18.4 (n = 275) 18.0 (n = 27) 16.9 (n = 12) 23.5 (n = 4) NS
Sex partners in past year
2 or less 79.9 (n = 620) 69.4 (n = 86) 64.6 (n = 42) 64.3 (n = 9)
3 or more 20.1 (n = 156) 30.6 (n = 38) 35.4 (n = 23) 35.7 (n = 5) p < 0.01
8 or less 91.2 (n = 705) 80.8 (n = 101) 69.2 (n = 45) 57.1 (n = 8)
9 or more 8.8 (n = 68) 19.2 (n = 24) 30.8 (n = 20) 42.9 (n = 6) p < 0.001
Binge drinking in last week
No 63.9 (n = 925) 52.4 (n = 76) 55.1 (n = 38) 71.4 (n = 10)
Yes 36.1 (n = 522) 47.6 (n = 69) 44.9 (n = 31) 28.6 (n = 4) p < 0.01
Monthly marijuana use
Never 87.3 (n = 1308) 70.7 (n = 106) 66.2 (n = 47) 75.0 (n = 12)
Once or more 12.7 (n = 190) 29.3 (n = 44) 33.8 (n = 24) 25.0 (n = 4) p < 0.001
Other illegal drug use
Never 95.6 (n = 1428) 90.7 (n = 136) 91.5 (n = 65) 93.3 (n = 14)
Once or more 4.4 (n = 65) 9.3 (n = 14) 8.5 (n = 6) 6.7 (n = 1) p < 0.05
Arrest other than traffic
Never 91.5 (n = 1373) 81.3 (n = 122) 87.3 (n = 62) 29.4 (n = 5)
Once or more 8.5 (n = 127) 18.7 (n = 28) 12.7 (n = 9) 70.6 (n = 12) p < 0.001
Reprinted from reference 26.
Stirn and Hinz [34] concluded that most people Given the link between body modification and “ex-
who partake in body modification clearly do not do it ternalized risk behaviors” in young people, tattooing and
because they have any psychological problems. However, body piercing may serve as clinical markers for health
for a few, modifications may be utilized as a convenient care professionals, potentially identifying those who
means to either realize psychopathological inclinations, may be involved in activities that hinder their health and
such as self-injury, or to overcome psychological traumas. development [29]. For example, closer examination of
The prevalence of self-injury is unknown, though it is teens who wear long sleeves or clothing inappropriate for
believed to be a growing problem. While self-injury is weather could reveal cuts, burns, carvings, or bruises that
believed to be a low-lethality behavior, teens who hurt are self-inflicted.
themselves are at increased risk for suicide related to their Patients are more likely to discuss the issue of body
underlying anxiety or depression. Moreover, self-harmers art if the clinician does not speak or act judgmentally
report that they often had their skin tattooed or body [1]. Practitioners who are concerned that their tattooed
pierced to help overcome a negative experience, or simply patient might be self-injuring or engaging in other risky
to experience physical pain. Another clue that self-harm behaviors should invite a discussion with the patient,
and piercing/tattooing might in some cases be linked perhaps using general terms, such as “Sometimes people
derives from the fact that many of the self-harmers said may get involved in self-injury and don’t know where to
they had ceased cutting themselves after obtaining their turn for help. I will try to help you if you are ever worried
first piercing or tattoo [35]. The increasing incidence about that.” As always, if the clinician suspects a patient
makes deliberate self-harm a problem that all health is engaged in self-harming activities, an immediate refer-
care providers dealing with adolescents are likely to ral should be made for mental health evaluation and any
encounter. necessary intervention.
318 JCOM July 2014 Vol. 21, No. 7 www.jcomjournal.comClinical Review
Preventatively, clinicians should provide targeted and Unfortunately, only 14% of the population identify health
repeated education to transmit the message of effective care professionals as a common resource for information
decision-making and evaluation of risks to children in on body modification. Instead, young adults endorsed
the early elementary grades, since some students start to friends (82%), body piercing shops (61%), and tattoo
obtain body art as early as fifth grade. shops (51%) as their top information sources. Clinicians
should help patients make informed decisions about body
Regret and Removal art and counsel them about the importance of universal
Over time, many individuals regret getting tattoos and precautions [35].
wish to have them removed [35]. In some cases, delayed
complications, like the development of allergic, hyper- Corresponding author: Susannah Grimm Poe, EdD, 176
Gilboa Rd., Fairmont, WV 26554, spoe@hsc.wvu.edu.
sensitivity, or granulomatous reactions, require tattoo
removal. On average, tattoo regret occurs 14 years after Financial disclosures: None.
tattooing and by the age of 40 years.
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