Continuing Education Activity
Body piercings have become increasingly popular and are a socially acceptable form of body modification. Common sites of piercings are the ears, mouth, nose, eyebrows, nipples, navel, and genitals. Localized cellulitis is the most common infectious complication resulting from body piercings. This activity reviews the evaluation and treatment of body piercing infections and explains the role of the interprofessional team in managing patients with this condition.
Objectives:
Review the role of the organisms Staphylococcus, Streptococcus, Pseudomonas, Neisseria, and Chlamydia in the etiology of body piercing infections.
Identify the risk factors for developing body piercing infections.
Summarize the use of conservative treatment including warm compresses and topical antibiotics in the management of body piercing infections.
Describe the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients affected by body piercing infections.
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 serioussystemic 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 a 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 havingreceived 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 issuesof 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 ifa disseminated infection is present.[8][9]It is essential to ask aboutwho performed the piercing, when did the piercing occur, and the equipment used to perform the procedure when evaluating apossible infectious complication from a body piercing.[1]
Evaluation
The diagnosis of minor localized infectionsis often based on the clinical presentation and does 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 tohave a lower infection rate but when present are treatable with amoxicillin/clavulanate. The recommended durationof 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 aid in infection healing. Treatment for genital piercing infections should include theconsideration to cover for Neisseria gonorrheaand Chlamydia trachomatis with intramuscular ceftriaxone and oral azithromycin in the appropriatesetting aside from the standard soft tissue infections. If the patient has not gotten a tetanus vaccination or boosterwithin the last five years, then this should be updated if presenting with an infection after a recentbody 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 appropriateantimicrobials. A delay in the 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 Ludwigangina, or possible dissemination 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 Bvirus, hepatitis Cvirus, 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 the localized infections to prevent severeand 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 2). Alternatively, it is not recommended to perform a swab, biopsy, or blood culture from a cellulitis infection (level 2). For abscesses, incision and drainage is the recommended treatment (level 1). 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 2). Recommended treatment duration is five days, but therapy extension is advisable if not improved during that treatment period (level 1).[9]
References
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Van Hoover C, Rademayer CA, Farley CL. Body Piercing: Motivations and Implications for Health. J Midwifery Womens Health. 2017 Sep;62(5):521-530. [PubMed: 28806494]
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Lee B, Vangipuram R, Petersen E, Tyring SK. Complications associated with intimate body piercings. Dermatol Online J. 2018 Jul 15;24(7) [PubMed: 30261561]
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Patel M, Cobbs CG. Infections from Body Piercing and Tattoos. Microbiol Spectr. 2015 Dec;3(6) [PubMed: 27337275]
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Stirn A. Body piercing: medical consequences and psychological motivations. Lancet. 2003 Apr 05;361(9364):1205-15. [PubMed: 12686054]
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Laumann AE, Derick AJ. Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol. 2006 Sep;55(3):413-21. [PubMed: 16908345]
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Bone A, Ncube F, Nichols T, Noah ND. Body piercing in England: a survey of piercing at sites other than earlobe. BMJ. 2008 Jun 21;336(7658):1426-8. [PMC free article: PMC2432173] [PubMed: 18556275]
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Kluger N, Misery L, Seité S, Taieb C. Body Piercing: A National Survey in France. Dermatology. 2019;235(1):71-78. [PubMed: 30404090]
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Clebak KT, Malone MA. Skin Infections. Prim Care. 2018 Sep;45(3):433-454. [PubMed: 30115333]
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Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC., Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52. [PubMed: 24973422]
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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. Epidemiol Infect. 2018 Jul;146(9):1177-1183. [PMC free article: PMC9134299] [PubMed: 29708089]
Disclosure: Dayton Preslar declares no relevant financial relationships with ineligible companies.
Disclosure: Judith Borger declares no relevant financial relationships with ineligible companies.
