Body Piercing Infections


Article Author:
Dayton Preslar


Article Editor:
Judith Borger


Editors In Chief:
Rhonda Coffman
Lindsay Iverson
Heather Templin


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
1/6/2019 12:08:03 AM

Introduction

Body piercings have become increasingly popular and a socially acceptable form of body modification. The most common site of piercings is the ear, with increasing popularity involving the mouth, nose, eyebrows, nipples, navel, and genitals.[1]  Localized cellulitis is the most common infectious complication resulting from body piercings. If not identified and treated accordingly these localized infections, though rare, can lead to more serious systemic complications such as Ludwig angina, endocarditis, toxic shock syndrome, and Fournier gangrene as detailed in case reports.[2]

Etiology

The most commonly identified organisms from body piercing infections include skin flora responsible for skin and soft tissue infections such as staphylococcus and streptococcus species though there are a few exceptions. There is a higher rate of incidence of pseudomonas infections when involving the cartilaginous ear and nasal structures.[3]Individuals with genital piercings are at increased risk for sexually transmitted infections such as Neisseria gonorrhea and Chlamydia trachomatis. Additionally, patients colonized with Staphylococcus aureus are at increased risk of infection regarding nasal piercing infections. Also, infection rates are low involving piercings of the lips and tongue despite the large number of bacteria present in the oral cavity.[4]

Epidemiology

A national survey found that of the respondents, approximately 35%, reported having some form of body piercings with 14% endorsing piercings at sites other than the soft earlobe. Women, in general, are more likely than men to have body piercings. Women additionally have more piercings to sites other than the soft earlobe when compared with males.[5] Individuals between the ages of 24 to 34 have the highest prevalence of body piercings. Of those individuals with piercings at sites other than the soft earlobe, 23% reported experiencing a medical complication. One-third of those with body piercings report having received piercings outside of a specified body art studio which raises the concern for increased infection transmission.[6][7]

Pathophysiology

Concerns over non-sterilized and improper cleaning techniques of piercing equipment, as well as, an individual patient's overall hygiene habits and poor piercing aftercare attribute to the increased risk of infection with associated body piercings.[3] There is a higher incidence of infection when involving the ear due to its poor blood supply leading to issues of wound healing. An additional concern arises with genital piercings that can compromise the integrity of barrier contraception and increase the risk for sexually transmitted infections.[3]

History and Physical

Most skin and soft tissue complications will present similarly to localized cellulitis infections or abscesses such as areas of erythema, swelling, warmth, tenderness, fluctuance, and possibly purulent drainage. More systemic symptoms such as fever, tachycardia, malaise, or changes in mentation can vary depending on the location and if a disseminated infection is present.[8][9] It is essential to ask about who performed the piercing, when did the piercing occur, and the equipment used to perform the procedure when evaluating a possible infectious complication from a body piercing.[1]

Evaluation

The diagnosis of minor localized infections is often based on the clinical presentation and do not require the need for extensive testing. Though indications for laboratory testing and imaging may not be present for every patient, some patients may need further evaluation when systemic symptoms like fever, tachycardia, hypotension, or altered mentation are present.[9] Common laboratory testing and imaging may include complete blood count, electrolytes, renal function, lactic acid, plain film x-ray or ultrasound.[8]

Treatment / Management

Conservative treatment of minor local infections includes warm compress and over the counter or prescription topical antibiotics such as bacitracin or mupirocin. Oral antibiotics such as cephalexin or clindamycin provide coverage for streptococcus and staphylococcus. If concerns for methicillin-resistant Staphylococcus aureus exist, then oral trimethoprim/sulfamethoxazole confers adequate coverage. Infected piercings of the high ear involving the cartilaginous structures are likely to be caused by Pseudomonas and are treatable with a fluoroquinolone like ciprofloxacin.

Removal of the piercing jewelry is requisite, and the placement of a loose loop suture through the piercing can be used to maintain the piercing patency throughout the duration of infection treatment. Oral piercings tend to have a lower infection rate but when present are treatable with amoxicillin/clavulanate. The recommended duration of treatment for local cellulitis is five days, but therapy duration extension is possible if there is no sign of symptomatic improvement.[9] The addition of oral alcohol rinses or topical cleaners containing carbamide peroxide can aide in infection healing. Treatment for genital piercing infections should include the consideration to cover for Neisseria gonorrhea and Chlamydia trachomatis with intramuscular ceftriaxone and oral azithromycin in the appropriate setting aside from the standard soft tissue infections. If the patient has not gotten a tetanus vaccination or booster within the last five years, then this should be updated if presenting with an infection after a recent body piercing. 

Differential Diagnosis

The differential diagnosis should be relatively straightforward with the complaint centered on the piercing site. Other possible diagnoses could include but are not limited to a retained foreign body, allergic reaction, deep vein thrombosis, sepsis from a disseminated local infection or representation of a bleeding disorder following the initial piercing.[2]

Prognosis

Complications arising from body piercing infections are rare, and antibiotic treatment along with incision and drainage of an abscess is the cornerstone of therapy.[2]

Complications

Potential complications of piercing infections are relatively minor when identified early and treated with appropriate antimicrobials. A delay in presentation can lead to increased severity of local skin and soft tissue infections such as abscess formation, nasal septal perforation, airway compromise with as in cases of Ludwig angina, or possible disseminated to distant sites such as endocarditis.[4] Lastly, complications of antimicrobial use have the known risk of Clostridium difficile colitis.[2]

Deterrence and Patient Education

Patients need to be counseled on the risks of associated infection when undergoing body piercings. Importance should be placed on infection prevention and the need for utilization of a trusted and certified piercing parlor as these locations have requirements for proper hygiene and sterilization techniques.[2]

 

Pearls and Other Issues

Rare reports exist of other infections including but are not limited to hepatitis B virus, hepatitis C virus, human immunodeficiency virus, and tetanus.[10] Complications of local infections can have grave implications with reports of toxic shock syndrome due to Staphylococcus aureus and associated ear piercing, endocarditis from nasal a nasal piercing, Ludwig angina from an oral piercing, and abscess formation compromising a breast implant after a nipple piercing, all have documented case reports.[4] For these reasons, it is necessary to identify and treat localized infection to prevent severe and life-threatening complications.[3]

Enhancing Healthcare Team Outcomes

Culture and gram stain of purulent drainage of skin infections can help aid in the treatment of skin and soft tissue infections, but this is not a requirement (level II). Alternatively, it is not recommended to perform a swab, biopsy, or blood culture from a cellulitis infection (level II). For abscesses, incision and drainage is the recommended treatment (level I). For infections involved with penetrating trauma, as could be the case with a recent body piercing, treatment with antimicrobials directed against methicillin-resistant Staphylococcus aureus and Streptococcus species are recommended (level II). Recommended treatment duration is five days, but therapy extension is advisable if not improved during that treatment period (level I).[9]


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Body Piercing Infections - Questions

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What is the appropriate treatment for a localized body piercing infection with associated underlying fluctuance, erythema, and warmth?



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A 33-year-old female presents with pain and redness to her left ear four days after receiving a piercing to the upper cartilage at a local tattoo and piercing parlor. Why are piercings involving the ear associated with increased complications?



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A 25-year-old male presents with three days of dysuria and redness with swelling to his penis. He admits to being sexually active with multiple partners with occasional use of condoms. On exam, he is noted to have a piercing to the glans of the penis, mild surrounding erythema, and white discharge from the urethral meatus. He endorses having received the genital piercing three weeks prior at a local tattoo and piercing parlor. What is the treatment of choice?



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A 17-year-old female presents with increasing discomfort to her naval with associated redness, induration, and a small amount of purulent drainage following a recent piercing to the same area. Which organism listed is most likely responsible for her symptoms?



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What is the appropriate treatment duration for a localized cellulitis skin infection?



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Body Piercing Infections - References

References

Stirn A, Body piercing: medical consequences and psychological motivations. Lancet (London, England). 2003 Apr 5     [PubMed]
Laumann AE,Derick AJ, Tattoos and body piercings in the United States: a national data set. Journal of the American Academy of Dermatology. 2006 Sep     [PubMed]
Bone A,Ncube F,Nichols T,Noah ND, Body piercing in England: a survey of piercing at sites other than earlobe. BMJ (Clinical research ed.). 2008 Jun 21     [PubMed]
Kluger N,Misery L,Seité S,Taieb C, Body Piercing: A National Survey in France. Dermatology (Basel, Switzerland). 2019     [PubMed]
Perry M,Lewis H,Thomas DR,Mason B,Richardson G, 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. Epidemiology and infection. 2018 Jul     [PubMed]
Stevens DL,Bisno AL,Chambers HF,Dellinger EP,Goldstein EJ,Gorbach SL,Hirschmann JV,Kaplan SL,Montoya JG,Wade JC, Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014 Jul 15     [PubMed]
Van Hoover C,Rademayer CA,Farley CL, Body Piercing: Motivations and Implications for Health. Journal of midwifery & women's health. 2017 Aug 14     [PubMed]
Lee B,Vangipuram R,Petersen E,Tyring SK, Complications associated with intimate body piercings. Dermatology online journal. 2018 Jul 15     [PubMed]
Patel M,Cobbs CG, Infections from Body Piercing and Tattoos. Microbiology spectrum. 2015 Dec     [PubMed]
Clebak KT,Malone MA, Skin Infections. Primary care. 2018 Sep     [PubMed]

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