Piercing

Piercing (from English to pierce "to pierce, pierce") is the insertion of jewelry in the form of rings, rods, barbells (special rod variant with thread and screwable balls) at various locations on the human body through artificially created perforations of skin, underlying fatty and/or cartilaginous tissue (Elsner P 2018).

While ear piercing has been a practice in Western culture for centuries, the practice of piercing on other parts of the body was long limited to ritual customs of primitive peoples. It has only become widespread among the European population in recent decades, with the punk movement playing a significant role in this regard (Elsner P 2018).

Meanwhile the offers of piercing products are completely confusing from the medical point of view. Companies offer >80.000 piercings. The following piercing procedures and products are offered:

• Eyebrow piercing
• ear piercing
• belly button piercing
• Nipple piercing
• Labret piercing ("Labret" refers to any form of lip piercing)
• Cheek piercing
• nose piercing
• tongue frenulum piercing
• tongue piercing
• genital piercing
• Prince Albert Piercing (here the ring is pulled through the exit of the urethra to the lower side of the glans of the penis)
• Surface piercing
• Uvulapiercing
• Lip frenulum piercing

14% of Americans and up to 19% of Europeans wear body piercings in different locations. Among American college students, it is as high as 60% of women and 42% of men. In a larger French study (n=5000) 25.8% of the respondents with body piercing were between 25 and 34 years old (Kluger N et al. 2019). In this French collective 19.4% women and 8.4% men were found. The frequency of ear piercings was 42%, navel piercings 24%, tongue piercings 15% and nose piercings 11% (Kluger N et al. 2019).

Health problems: Professionally performed and well maintained piercings normally do not cause any problems and do not represent any danger. Acute complications of a piercing depend on the experience of the piercer, the hygiene during and after the procedure and the basic care of the piercing (Perry M et al. 2018).

With all forms of piercing there can be local swellings and light bleedings, which usually subside after a while.

Local reactions:

• Bacterial infections: With all forms of piercing there can be local swelling and light bleeding, which usually subside after a while. Local wound infections are the most frequent complication of piercing with 36% of all affected persons (Perry M et al. 2018). Especially easily piercings through the ear cartilage lead to superficial wound infections but also to bacterial chondritis. Pathogens are mainly Pseudomonas spp. and Staphylococcus aureus (Bellaud G et al. 2017). Frequently (10-20%) are local infections caused by Staphylococcus aureus, Group A Streptococci and Pseudomonas aeruginosa (Evans H et al. 2018). Wound healing disorders should be considered especially in patients with immunosuppression (immunosuppressive therapies, collagenosis, diabetes mellitus). Further reports are available on tetanus and tuberculosis infections. Piercings in the perineal area can cause permanent inflammations due to prolonged sitting. Furthermore, life-threatening cases of Fournier`scher-Gangrene after genital piercing have been described (Ekelius L et al. 2004).
• Viral infections: Viral infections have been reported (transmission of hepatitis viruses B, C, D and G and of HIV and condyloma acuminata - Yang S et al. 2015; Sahlan N et al. 2019).

Endocarditis prophylaxis: In patients with pre-existing cardiac diseases, especially those with heart valve carriers, the risk of endocarditis is significantly increased (Werner O et al. 2019). Therefore, endocarditis prophylaxis is recommended for these high-risk patients.

Sensitization through piercings: Sensitization against nickel with consecutive contact allergic eczema is the most frequent allergic complication of piercing (Warshaw EM et al. 2017). In a cross-sectional analysis of piercing pins the nickel release was 0.35 µg / cm2/week in 26 of 160 pins (Uter W et al. 2018). Suitable are piercing materials of stainless steel, titanium, niobium and PTFE, materials, whose nickel release does not exceed 5 ng/cm2/week by abrasion.

Hypertrophic scars and keloids: Such complications are mainly found with ear piercings. In these cases the piercing material must be removed.

Piercing damages of the teeth: Piercings in the oral area (tongue, lip, frenulum of the lips) basically hold a risk potential for teeth and for the periodontium (Tomaževič T et al.2017). The metal button of a tongue piercing can lead to traumatisation of the tooth cusps and the gingiva located towards the tongue. This permanent traumatisation can ultimately lead to the destruction of the affected tooth. If non-metallic jewellery (acrylic or horn material) is used, the risk of tooth damage is lower due to the lower hardness of the material.

Problems with genital piercings: An unhealed wound from genital piercing increases the risk of infection with sexually transmitted diseases (hepatitis B, hepatitis C or HIV). Wearing a condom is mandatory for unhealed genital piercings.

Miscellaneous:

• Nerve damage: When piercing eyebrows or the nostrils, branches of the trigeminal nerve can be damaged.
• Traumatisation: With the Prince Albert piercing too thin rings (up to about 2 mm material thickness) can cut through the tissue when mechanically stressed.
• Local frostbite through piercings: At temperatures below minus ten degrees Celsius frostbite can occur with open worn piercings of metal jewelry (metal conducts the heat better than organic tissue). Especially piercings in the facial area are affected.
• Piercings at security checks (metal detector): Mostly the detectors used at security checks at airports do not react on piercings (the amount of metal is normally below the alarm threshold). However, if several piercings are close together or if voluminous jewellery is worn, this can lead to a metal detector alarm.
• Piercings and imaging techniques: With CT devices, a piercing is imaged in a shadow. Thereby dorsally situated structures are covered (e.g. with nipple piercing an underlying carcinoma).
• With MRT examinations (magnetic resonance imaging) there is the possibility of heating the piercing material. Furthermore a high tensile force can be exerted on the jewellery, if it contains ferromagnetic metal.

1. Bellaud G et al (2017) Bacterial chondritis complications following ear piercing. Med Mal Infect 47:26-31.
2. Ekelius L et al. (2004) Fournier's gangrene after genital piercing. Scand J Infect Dis 36:610-612.
3. Elsner P (2018) Dyschromas, piercings and tattoos. In: Braun-Falco`s Dermatology, Venerology and Allergy. Springer Reference Medicine. S. 1301-1302
4. Evans H et al (2018) National outbreak of Pseudomonas aeruginosa associated with an aftercare solution following piercings, July to September 2016, England. Euro Surveill 23(37).
5. Kluger N et al (2019) Body Piercing: A National Survey in France. Dermatology 235:71-78.
6. Perry M et al (2018) Need for improved public health protection of young people wanting body piercing: evidence from a look-back exercise at a piercing and tattooing premises with poor hygiene practices, Wales (UK) 2015. epidemiol Infect 146:1177-1183.
7. Sahlan N et al (2019) Hepatitis B virus infection: Epidemiology and seroprevalence rate among Negrito tribe in Malaysia. Med J Malaysia 74:320-325.
8. Tomaževič T et al.(2017) Occurrence of Dental Injuries and Periodontal Complications in Tongue-piercing Jewellery Users. Oral Health Prev Dent 15:293-297.
9. Uter W et al (2018) Nickel and cobalt release from earrings and piercing jewellery - analyticalresults of a German survey in 2014.contact dermatitis 78:321-328.
10. Warshaw EM et al (2017) Piercing and Metal Sensitivity: Extended Analysis of the North American Contact Dermatitis Group Data, 2007-2014.Dermatitis 28:333-341.
11. Werner O et al (2019) Factors influencing the participation of adolescents and young adults with acongenital heart disease in a transition education program: A prospective multicentre controlled study. Patient Educ Counspii: S0738-3991(19)30256-3.
12. Yang S et al (2015) Transmission of Hepatitis B and C Virus Infection Through Body Piercing: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 94: e1893.