Allergic reactions
Piercings can also be the cause of allergic contact dermatitis to metals, especially during the healing period. Jewellery, in fact, is the most common cause of sensitisation to nickel sulfate. The allergic reactions can be connected to the different materials of which the jewellery is made, such as surgical steel (an alloy containing carbon, chromium, nickel, molybdenum, and iron); inert materials, such as titanium and niobium, that may contain traces of nickel; and gold that must be at least 14 karat (58.3% gold) or, in the case of recent piercings, at least 18 karat gold (75% gold). Other items used such as gloves, antiseptic, or anaesthetic can also cause immediate or delayed hypersensitivity reactions1, 37, 44–46.
Hypertrophic scars
Piercings can cause hypertrophic or keloid scars (overgrown scar tissue around the area), which are particularly common in areas such as the pinnae and the upper chest, which is one of the most common sites for surface piercing or pocketing. Piercing guns, typically used to pierce ears, cause most cases of excessive scarring owing to the inflammatory response they trigger. Anybody with a history of hypertrophic or keloid scars should be advised against the risks connected to body piercing. Patients who are taking or have recently taken isotretinoin should also be advised to wait before getting a body piercing given the risk of abnormal scarring associated with this drug1, 37, 47.
Bleeding
Another common complication associated with piercings is bleeding, which can be considerable in certain sites, such as the tongue; in certain circumstances, such as the use of anticoagulants or antiplatelets; or the presence of blood disorders, such as haemophilia and low platelet levels1,37,48,49.
Implanting
Implanting is the placement of materials such as Teflon® (DuPont, Wilmington, DE, US), plastic, or steel under the skin to create decorative shapes or to reshape the silhouette of the face or other body parts. All piercing-related complications apply for implanting, but material rejections, haemorrhage, delayed wound healing, and severe infections are more common in implanting. Also implants could be displaced in case of emergency and could hinder important diagnostic procedures1,37.
Branding and scarification
Branding and scarification lead to patterns of permanent scars by making superficial incisions on the skin using different procedures, such as electrocaustic methods, chemicals, laser, heated metals, or freezing for artistic or cultural reasons. The technique consists of making incisions as far as the dermis, with or without the removal of tissue, so that the subsequent healing by secondary intention will cause permanent scars. In most cases, the aim is to create a hypertrophic scar in order to produce a raised scar form. The practice dates back to ancient times and used to denote social status or symbolise beauty in the members of a tribe. Scarification is common in certain cultures in parts of Africa and Australia, but the practice also became popular in other parts of the Western world as an alternative to tattoos1,37.
Adverse skin reactions caused by branding and scarification
The scar healing process cannot be controlled, and patients can develop keloids. Such keloids may not only be aesthetically unpleasant, but also cause functional problems such as limited mobility. Branding and scarification are more painful procedures than other body decoration methods and can be also associated with a greater risk of local and systemic infections. Allergic reactions are also possible, depending on the method used1,37.
Conclusions
Body modifying art is a relatively safe procedure when performed by professional artists who have received education on appropriate hygiene techniques and apply strict sanitary precautions in their shops. However, the reports of complications remind us of the importance of improving the safety of these techniques to preserve the health and skin physiology of customers9,50.
In the Tuscany region of Italy, those who want to become a tattoo artist or piercer must have a professional qualification that can be obtained by attending a 600-hour course, according to the minimum standards required by Regional Law 28/2004 and the implementing regulation. The activity can then be exercised by submitting a statement of commencement of activities (Dia) to the municipality territorial jurisdiction, which verifies the minimum structural, managerial, and sanitary system required by law, and then grants authorisation.
Body art is a phenomenon predominantly taken up by adolescents and young people, and for this reason resources should be invested in health promotion. Family physicians, dermatologists, school educational staff, and counsellors should assist adolescents to become better informed decision-makers, prevent risks, and, if appropriate, dissuade them from tattooing, body piercing, or any other body modifying techniques. It is appropriate dissuade young people from having body art (especially permanent procedures) if they are not sure, but they feel pressure from peers or just to follow fashion and trends. Guidance and health education should be steered towards ensuring that individuals who are more likely to opt for body art and who are at greater risk of complications, are efficiently targeted by school teachers and family physicians12.
It is important for the dermatologist to be able to identify localised reactions, as well as signs of systemic disease or infection caused by piercing, tattooing, and other body modifying practices. Erythema, oedema, and pruritus extending beyond the borders of a tattoo, associated warmth, pustules, and any papulonodular growth within the tattoo pigment requires the correct diagnosis and treatment. Patients with systemic or cutaneous conditions, risk factors for melanoma, or other cutaneous malignancies require counselling from primary care physicians, or cardiologists for those with cardiac valve disease. Those who decide to obtain a body modifying procedure should be advised to contact their physician or a dermatologist if any symptoms occur51.
