Elisa Hae-Jung Song, MD

Decorating the "human canvas": 
 Body art and your patients 

By Steven Martel, MD, and Jane E. Anderson, MD 

 Tattoos and body piercing have caught on as teenage, and even preteen, fashion statements. Here's how to help your patients avoid the pitfalls of this form of self-expression.

 Tattooing and body piercing are gaining popularity among youth as more preteens and adolescents choose to adorn their bodies with often permanent decorations. Because these venerable forms of body art (see "

"), and the more extreme practice of branding, are associated with definite medical risks, pediatricians must be able to provide accurate information to their patients as well as recognize and treat complications.

 Self-report surveys indicate that 8% to 13% of adolescents between 12 and 18 years of age have a tattoo. Of those who do not, 30% to 50% have considered getting one.

 Myrna L. Armstrong, EdD, RN, who has published extensively on body art in adolescents, conducted two surveys of tattooing in urban high schools in 1993 and 1995. In 1993, she questioned 642 teens in Texas and found that 8.6% had a tattoo. Of those, 65% reported academic grades of A or B. When she surveyed 1,762 students across the United States two years later, 9% reported having a tattoo, and 60% of them earned academic grades of A or B. Clearly, teenagers today who sport a tattoo do not fit the stereotype of low academic achievement attached to youth with tattoos in the early 20th century. The mean age at first tattoo declined from 16 years in 1993 to 14.5 years in 1995.

 Boys generally get a tattoo at a younger age than girls do.

 More than half of tattooed adolescents describe themselves as "risk takers," and about a quarter report having used alcohol or other drugs before getting the tattoo.

 A 1991 survey of 474 adolescents found that tattooing was associated with low self-esteem, delinquency, drug abuse, and dropping out of school.

In 1998, Stuppy and colleagues reported that adolescents with a tattoo were perceived negatively by health- care providers, even as the rate of tattooing increased among adult professionals.

 The most recent study of adolescentsa survey by Carroll and colleagues of 484 teenagers at a naval medical centerdocumented that even though tattooing and body piercing are becoming more prevalent, teens who participate in these forms of body art are more likely to also engage in risk taking behaviors, including disordered eating behavior, drug use, sexual activity, and suicide.

 The authors note that as the number of body piercings increased, the abuse of drugs such as cocaine, crystal methamphetamine, and Ecstasy also increased. Pediatricians, therefore, need to pay more attention to screening teens for high-risk behavior if they have tattoos or body piercings.

 Tattooing, along with piercing and branding, are sometimes marks of gang membership. Wearing tattoos of dots, crosses, and webs in the thumb-forefinger interspace may indicate gang affiliation; a tear drop or spider web may mean that the gang member has murdered someone. Prisoners often engage in tattooing as a sign of strength, using the carbon from burned pieces of paper as pigment. Although women traditionally have been reluctant to be tattooed, the incidence of tattooing among adult women has quadrupled in the past 25 years.

 Body piercing seems to have more public acceptance than tattoos. Almost 27% of the 484 adolescents in Carroll's study had at least one body piercing, and almost 12% had more than one.

 Girls were more likely than boys to have body piercings (36.7% vs. 10.1%) and were also more likely to have tattoos (16% vs. 8%).

 The earlobe and ear cartilage are the most popular piercing sites and long past being remarked on in our culture. Other sitesincluding the lips, eyebrows, nose, tongue, navel, nipples, and genitalsare gaining in popularity, however (Table 1). One study demonstrated that patients with genital piercing were at higher risk of contracting a sexually transmitted disease.

Arm/hand 
 Chest 
 Back/shoulder 
 Abdomen 
 Hip/leg/foot 


 Ear/ear cartilage 
 Nose 
 Navel 
 Tongue 
 Lip 
 Eyebrow 
 Nipple 

 The impact on adolescents of tattooing and body piercing among celebrities has not been studied. As more celebritiessuch as professional basketball player Kenyon Martin, who appeared with a tattoo on the April 29, 2002 cover of 

 expose their tattoos and piercings, we would expect adolescent behavior to be affected.

 Adolescents give many reasons for acquiring body art. In one study, 19% of tattooed teens said they "just wanted one," 17% said they wanted to be "a part of the group," 12% said they did it "just for the heck of it," and 38% said they felt like being deviant at the time they were tattooed.

 In another study, 44% of adolescents with tattoos said they "just wanted one," and 23% said they did it to express independence. Fewer than one third of the parents of these teens knew about the tattoo at the time it was applied.

 getting a tattoo include the permanence of the art, the risk of infection, and parental disapproval. Cost does not appear to be a factor in decision making.

 The tattooist shaves the area to be tattooed and draws or stencils the design on it, taking into account the movement of the skin in the area. The most common designs are names, crosses, animals, cartoon characters, freehand designs, and hearts. The skin is then sprayed with an antiseptic solution and lightly covered with a layer of petroleum jelly. The tattoo machine, which fits into the palm of the hand, consists of a needle bar with various numbers of needles attached. The tattooist first makes an outline of the design with an outline bar that has three to five needles attached. The needles move up and down inside a tube, vibrating 50 to 2,000 times a minute. They extend beyond the tip of the tube to push ink into the skin to depths of 

 in. The pain may be more intense during the outlining procedure than during other phases of tattooing because the needle remains in contact with the skin longer.

 When the outline is complete, the tattoo design is colored with a "shader" that has five to 13 flat needles and five to seven round needles attached to the bar. Depending on the size and detail of the tattoo, the process can take from 15 minutes to several sessions. It usually causes quite a bit of bleeding, and the machine must be stopped often to wipe away the blood. The tattooist should wear gloves during the procedure, and all equipment must be disposable or sterilized in an autoclave.

 Most colors are not actually ink but rather pigments that are mixed with a carrier. The pigment may be a naturally occurring mineral, a vegetable, or an acrylic plastic. Tattoo pigments are not well regulated and may contain a combination of powders of carbon, wood, and metals (iron, copper, aluminum).

In order to decrease the risk of infection, only tattoo inks and pigments that come in single-use containers should be used. Red ink or pigment causes the highest incidence of allergic reaction. Red, yellow, and dark green pigments are the most difficult to remove. Carriers include alcohol, filtered water, and USP glycerin. Carriers with an alcohol content of 15% or higher have a sterilizing effect.

 Teenagers often obtain tattoos from friends or other amateurs or tattoo themselves using straight pins, pencils, or pens and mascara, charcoal, or dirt as pigments. In one study of 464 high school students in Western Australia, more than 13% had a tattoo, and most were self-administered.

These types of tattoos carry a high risk of infection and reactions to the materials used as pigments.

 To minimize bleeding during tattooing, no alcohol or nonsteroidal anti-inflammatory drugs such as aspirin should be taken before the procedure. Excess bleeding can cause the ink to leave the area of the tattoo. Most tattoo professionals will not perform the procedure on people with a bleeding disorder or those who have difficulty healing, such as diabetics.

 Preparation for piercing is less complicated than for tattooing, requiring only sterilization of the skin. Ice may be applied to the piercing site for its anesthetic effect since local anesthetics can be administered only by physicians. Spring-loaded guns are often used, but because they cannot be sterilized properly, individual, sterilized needles are the recommended instruments.

 Pediatricians sometimes offer piercing services (see "

Best place to pierce young ears? The pediatrician's office

"). At least one commercially available piercing instrumentthe Blomdahl ear piercing system, which features medical grade titanium piercing studs encapsulated in sterilized, disposable cassettesis marketed exclusively to physicians to promote safe, sterile ear piercing.

 Jewelry inserted at piercing sites should be made of noncorrosive metals, such as surgical stainless steel, titanium, or solid 14 K gold. Nickel should be avoided because of its marked tendency to cause allergic reactions. Jewelry must be chosen carefully to accommodate the tissue swelling that follows piercing. A bar placed in the tongue, for example, must be long enough to allow for the expected swelling, and the studs should not be attached too tightly.

 Piercing is viewed as less permanent than tattooing because the jewelry can be removed. Piercing may leave scars, however, and keloid formation may occur during healing.

 Branding is done by pressing an extremely hot piece of metal onto the skin. Because individual brands used for body art usually comprise only a portion of the design, several "strikes" or pressings are often necessary to form the complete design. Brands are generally placed on a flat skin surface and should not be placed close to vital organs. The shoulders, upper back, and thighs are common sites. As the skin heals, raised scars are formed. Many objects that might be used for branding by amateurs, such as kitchen utensils, are inappropriate because they do not maintain heat or shape, causing an irregular design.

 Because of intense pain, potential for serious complications such as infection and damage to underlying tissues or organs, lack of professional regulation, and need for special expertise, branding is considered the most dangerous form of body art. Pediatricians would be wise to counsel patients against branding.

 Tattoos must be carefully attended to for the dye and design to remain constant. Most tattooists recommend keeping the tattoo bandaged for 12 to 24 hours, then washing with warm soap and water. All blood and soap should be removed and an antibiotic ointment or fragrance-free lotion (Lubriderm or Eucerin) applied three times a day for a week. Most tattooists advise against applying petroleum jelly, rubbing alcohol, or peroxide. The tattoo should not be allowed to dry or exposed to direct sunlight for two weeks. Patients with a fresh tattoo should also avoid swimming, hot tubs, and prolonged bathing for several weeks.

 Body piercings can take four weeks to a year to heal completely, depending on where they are located (Table 2, available in the print edition: Freyenberger B, Tattooing and body piercing: Decision making for teens. 

 The pierced site must be kept clean by washing twice daily with an antibacterial soap, paying particular attention to sites that are exposed to sweat. Salt water soaks are often used to remove any crusting. Alcohol, peroxide, and povidoneiodine (Betadine), which can discolor gold jewelry, should not be applied to the site.

 Clothing and objects such as glasses that come in contact with the new piercing should be clean and loose fitting. Because tight clothing can cause irritation and inhibit healing, patients who have a navel piercing must avoid restrictive items such as belts and body suits. They should also avoid hot tubs until the piercing heals. Tongue piercings must be cleaned by rinsing with antibacterial mouthwash.

 The most common complications of tattooing and piercing are bleeding and infection. Information on complication rates is difficult to obtain. One review of the medical literature on body piercing found the following complication rates for ear piercing: redness and swelling 30%, drainage 26%, infection 24%, bleeding 11%, and large scars 3%.

 In a study of 105 patients seeking removal of tattoos, 4% recalled skin irritation and 3% listed photosensitivity as complications of the procedure.

 In another study of 213 tattooed adolescents, 68% reported some bleeding after the procedure.

 Sources of infection are many and include the ink well and dye containers, the needles, the tattoo bar or piercing gun, lack of barrier precautions such as gloves, and improper skin preparation. Careful investigation of the tattoo or piercing shopincluding whether it sterilizes equipment and uses one-time ink cartridges that are discarded after each customercan reduce the risk of infection. Because of the potential for infection, persons who have had a tattoo or piercing may not donate blood for one year. The Food and Drug Administration (FDA) is reconsidering the one-year ban on blood donation if potential donors can prove that their piercing or tattoo was done in a sterile manner.

 Both bacterial and viral infections have been reported. Carbuncles, impetigo, and cellulitis are fairly common. 

 is the most often reported microorganism and has been known to cause bacteremia, osteomyelitis, meningitis, and toxic shock syndrome after ear piercings. 

 infections requiring surgical incision and drainage or resection of necrotic cartilage also have occurred after ear piercings,

 as have erysipelas, septic arthritis, glomerulonephritis, and endocarditis caused by Group A b-hemolytic 

infection also have been reported. Interestingly, at least 60 cases of syphilis transmission by tattooing occurred before 1945 when tattooists held the tattooing needles in their mouths, allowing the spirochetes in saliva to infect equipment.

 Viral infections, including those caused by human papillomavirus, herpes simplex virus, and hepatitis B, C, and D viruses, all have been reported, but no case of human immunodeficiency virus (HIV) infection has been attributed to body art. The long incubation period for HIV makes correlation difficult. Several studies show an association between ear piercing and hepatitis B seroconversion, including several cases that resulted in fulminant hepatitis and death.

 Local skin irritationerythema, dryness, tendernessis another common complication of body art. Unwanted keloid formation and sarcoid-like granulomas may result from both piercing and tattooing.

 Allergic reactions to the ink pigments and metallic jewelry occur fairly often. Tattoo clients are often advised to have an unexposed area of skin tested with the ink or pigment to assure that they are not allergic to it. It is also possible to develop an allergy to dye in a tattoo that the patient has had for years. In a study of patients with contact dermatitis, women with pierced ears were much more likely to demonstrate nickel sensitivity than those whose ears were not pierced.

 A patient in Canada experienced excruciating pain during an MRI because of iron oxide in the pigment of a small flower tattoo.

 Other reports document blurring of the MRI image.

 Some complications are site specific. Tongue piercings can cause severe edema of the tongue (occasionally leading to airway obstruction), damage to teeth and oral mucosa, and aspiration. They can also interfere with chewing and speech. Nipple piercings in a woman may disrupt milk ducts, interfere with later breastfeeding, and contribute to development of breast abscess. Prince Albert ringspiercings through the penis and penile urethrahave caused urethral rupture.

 Athletes are usually asked to remove visible body piercings, including tongue studs, before participating in sports to avoid injury.

 The FDA is monitoring consumer complaints regarding complications from tattoos and tattoo removal. Physicians and patients can report complaints to Cosmetics Adverse Reaction Monitoring (CARM), HFS 106, 200 C Street NW, Washington, DC 20204 (or call 202-205-4706).

 An interesting side effect of body art is the potential for addiction in some people. It is not known how many body art aficionados become addicted to the process, nor is it clear why this happens. It has been speculated that some people enjoy the painful procedures, possibly because of the release of endorphins.

 Because of the risk of complications, patients with certain medical conditions should be advised against tattoos and piercings. These conditions include diabetes, thrombocytopenia, neutropenia, hemophilia, endocarditis, cancer, and keloid formation.

 Removing tattoos: Easier wished for than done 

 Many adolescents later express regret about permanent body art and want it removed. One study of 163 people with tattoos found that 21.5% regretted the quality of the tattoo and 8.6% regretted the design.

 The study did not provide data on removal attempts. In Houghton's study of teens in Western Australia, 44% regretted having a tattoo. The reasons they gave for tattoo removal included boredom with the design and a desire to be viewed with more respect by their peers. Some of the teens in the study had attempted to remove their own tattoos using scissors, razor blades, and even a potato peeler.

 In another study of 105 adults who requested tattoo removal at a dermatology clinic, 63% said that their tattoos were not helpful and contributed to a sense of embarrassment (61%) and "lowered body image" (26%).

 Most (85%) said they were seeking laser treatment for tattoo removal to improve their self-esteem. Almost half of them, however, reported having been pleased with the results at the time their tattoos were applied. Other reasons for regretting a tattoo include a terminated relationship with the subject of the tattoo, an allergic reaction, poor tattoo quality, and a life change, including job requirements.

 Tattoos also may be removed as part of a gang rehabilitation program. In California, for example, a 1997 law provides for removing a tattoo if it is deemed to present a threat to the owner's personal safety or an obstacle to employment. In return, 20 hours of public service are required. D-TAG, a tattoo removal program in Dallas, was started by a school nurse and includes resources to rehabilitate the gang member.

 Tattoos may be covered temporarily with special makeup, as is done by movie actors and actresses. The design of a tattoo can be altered permanently by injecting new pigments to change or camouflage the pattern.

 Removing a tattoo may cost more than $1,000, depending on the size of the design. Before the development of lasers, tattoos were removed by salabrasion (rubbing salt into the tattoo) or dermabrasion (scraping skin down to the dermis). Both techniques cause severe scarring.

 Now, three different Q-switched lasers are available for tattoo removal. These lasers store large amounts of energy and discharge it in a very short period of time (nanoseconds) to mechanically disrupt the pigment particles in the tattoo. The smaller particles that result can then be removed by macrophages. The ruby laser removes blue-black and green pigments, and the Nd-YAG (neodymium-yttrium-aluminum-garnet) laser removes blue-black and red pigments. The alexandrite laser removes blue-black pigments. Local anesthesia may be used, and several treatment sessions are required, even for small tattoos.

 Realistically, patients should expect residual scarring or pigmentary changes, and transient hypopigmentation often occurs. Patients prone to keloid formation may be more likely to form keloids during the removal process.

 Temporary, or fake, tattoos are readily available in many craft stores and have been used since the early 20th century. (Small tattoos were among the original prizes in boxes of Cracker Jacks.) Temporary tattoos can be cheap and easy to apply or more sophisticated and expensive when liquid paints are used for additional coloring. Fake body piercing devices, which often use a magnet to hold the jewelry in place, also are available.

 These temporary decorations allow a teenager to experiment with designs and placement without risking the complications and permanence of true tattoos and piercings. Allergic reactions to the dyes in temporary tattoos can occur, however.

 Although tattooing supply sales are increasing rapidly and the risks of infection and contamination by pigments are clear, the FDA neither inspects tattoo pigments nor regulates their manufacture. Inks and pigments are listed as "color additives" that are not approved for intradermal injection.

 Regulatory oversight of tattooing and piercing facilities varies from state to state. A review of statutes enacted by individual states reveals that 12 states have regulations concerning infection control measures, 11 forbid tattooing of minors, and seven prohibit tattooing. The remaining 27 have no laws.

 In January 1998, researchers surveyed all 50 states and the District of Columbia to determine whether tattooing and body piercing facilities were regulated. At that time, 13 states regulated tattoo facilities and three states were considering legislation. One state (Oklahoma) had outlawed tattooing. Only four states regulated body piercing facilities.

 In California, to cite one example of regulations, it is a misdemeanor, punishable by a fine of $250, to pierce the genitals of or to tattoo anyone under 18 years of age. Tattoo and piercing facilities are licensed. To obtain a licence, the facility must pay a registration and inspection fee, acknowledge receipt of health department guidelines for preventing the spread of infectious diseases, and agree to an annual inspection. Persons who perform tattooing or body piercing do not have to demonstrate competency in the procedures.

 In light of the relative permanence of tattooing and branding and the potential complications of all forms of body art, pediatricians need to provide their patients with anticipatory guidance about this increasingly popular fashion statement (see the Guide for Patients, "

Tattoos and body piercing: What you need to know

"). By educating ourselves we can become a credible resource for patients who are considering body decorations and, one would hope, decrease the incidence of many of the complications.

1.	Armstrong ML, Murphy KP: Tattooing: Another risk behavior warranting health education. 

 	2.	Farrow JA, Schwartz RH, Vanderleeuw J: Tattooing behavior in adolescenceA comparison study. 

 	3.	Stuppy TJ, Armstrong ML, Casals-Ariet C: Attitudes of health care providers and students toward tattooed people. 

 	4.	Carroll ST, Riffenburgh RH, Roberts TA, et al: Tattoos and body piercings as indicators of adolescent risk-taking behaviors. 

 	5.	Samantha S, Tweeten M, Rickman LS: Infectious complications of body piercing. 

 	6.	Armstrong ML: Motivation for tattoo removal. 

Coping with the Dangers of Tattooing, Body Piercing, and Branding

. New York, Rosen Publishing Group, 1998, pp 310, 2225, 41, 109 

 	8.	Houghton SJ, Durkin K: Amateur tattoing practices and beliefs among high school adolescents. 

 	10.	Freyenberger B: Tattooing and body piercing: Decision making for teens. Virtual Hospital 

 	11.	Koenig LM, Carnes M: Body piercing: Medical concerns with cutting edge fashion. 

 	12.	Armstrong ML, Stuppy DJ, Gabriel DC, et al: Motivation for tattoo removal. 

 	13.	Long GE, Rickman LS: Infectious complications of tattoos. 

 	14.	Johnson CJ, Anderson H: Ear piercing and hepatitis. 

 	15.	McDonagh AJG, Wright AL: Nickel sensitivity: The influence of ear piercing and atopy. 

 	16.	US Food and Drug Administration Center for Food Safety and Applied Nutrition: Tattoos and permanent makeup. November 29, 2000 

. Princton, N.J., The Pyre Press, 1971, p 56 

 	18.	Tope WD: State and territorial regulation of tattooing in the United States. 

 	19.	Braithwaite RL, Stephens T, Sterk C, et al: Risks associated with tattooing and body piercing. 

DR. MARTEL is a clinical instructor in pediatrics at the University of California, San Francisco. 

 DR. ANDERSON is clinical professor of pediatrics at the same institution.

 Although teenagers get their ears pierced in a variety of places, including malls and friends' bathrooms, the safest place to have the procedure done is a physician's office. Not all physicians pierce ears, but parents and teens should seek out one who does, says Lisa M. Asta, MD, a pediatrician who performs ear piercing in her Walnut Creek, Calif., office. Ear piercing is a surgical procedure, albeit a minor one, and subject to complications such as infection, she emphasizes.

 "When you go to a physician's office, the entire procedure is sterile," Dr. Asta says. Although larger chains of ear piercing establishments likely have strict policies and procedures, many mall-based establishments are staffed by teenagers who may not recognize the importance of strict sanitation, she points out. Once the ears have been pierced, Dr. Asta says, "parents need to keep after their children, making sure they clean the earrings and wait six weeks before changing them. Studs should remain in place for three months before changing to hoops."

 Children and teens are not the only ones who have their ears pierced. Piercing an infant's ears is still a common occurrence in pediatricians' offices, and parents need to be made aware of the potential risks of performing the procedure at such an early age, notes Dr. Asta. Besides infection, they include:

 tearing of the ear lobe if the baby rips the earring out 

Articles

Tattoos and body piercing have caught on as teenage, and even preteen, fashion statements. Here&s how to help your patients avoid the pitfalls of this form of self-expression.

Elisa Hae-Jung Song, MD

Articles

Decorating the "human canvas": Body art and your patients