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Infectious Complications of Body Art: Infection is reported in about 1% of tattoos and in up to 45% of piercings, depending on the technique employed, body location, and after care

Playe, Stephen J. MD

doi: 10.1097/01.EEM.0000334232.52899.06

Dr. Playe is an assistant professor of emergency medicine at Tufts University School of Medicine and the residency program director for emergency medicine at Baystate Medical Center in Springfield, MA.

Body art, defined as tattooing or piercing of a body part, is increasingly common in modern Western society. Tattooing dates back to prehistoric times as a form of permanent body decoration to express individuality, identify a person, mark a rite of passage, or create a cosmetic effect. Body piercing is an ancient practice performed to enable adornment with jewelry. Estimates of the current frequency of tattooing among U.S. college students ranges from 23 to 75 percent, and the frequency of body piercing ranges from 33 to 51 percent.1–3

Both practices entail instrument penetration through the epidermis, and infection is reported in about one percent of tattoos and in up to 45 percent of piercings. The risk of infection depends on the technique employed, the body location, the after care of the site, and the underlying health of the decorated person.

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In the absence of prospective studies on the risks associated with body art, information is based on case reports and basic principles of communicable diseases. Certainly any open wound can become infected by skin and environmental microbes. Wound infections are rare in the shallow (1–2 mm) punctures of tattoos that heal quickly. Skin infections are more common in the deep puncture wounds of piercings, and these may remain inadequately healed and at risk of microbial invasion for months or even years. (See table.) Wound infections may lead to bloodstream infection, and have the potential to seed distant sites.



Figure. I

Figure. I

Local infection must be differentiated from the expected inflammatory response of healing. Swelling, especially of the tongue, is normal in the first few days after piercing. A thin, scant whitish-yellow secretion that crusts on the jewelry, and is associated with localized induration is a normal reaction and may persist throughout the healing period. Even after healing, some piercings may secrete sebum. While this may be malodorous, it is not a sign of infection.

Infection is generally manifested by warmth, spreading erythema, or copious yellow-green discharge. Fever may be present. Infections can develop at any time during the prolonged healing process. Cellulitis and abscesses caused by staphylococci and streptococci are the most common infections after piercings of all types. Certain locations, however, have unique complications.

Earlobe piercing is so common in our society that it is not even considered body piercing for regulatory legislation or surveys of prevalence. Infection occurs 11 to 24 percent of the time, and is caused by common skin pathogens. The incidence of infection is highest when piercing “guns” are employed. Unless they have disposable cartridges, these devices cannot be fully sterilized. Additionally, they traumatize the tissue by bluntly forcing the jewelry stud through the ear.

High ear piercings of the helix, tragus, or antitragus perforate the cartilage, and are associated with a greater risk of infection than standard ear lobe piercings. Benzalkonium chloride, a low-level disinfectant that is not effective against Pseudomonas species, is frequently used to cleanse the ear prior to piercing. The combination of incompletely disinfected skin, blunt trauma with a non-sterile gun, and an open wound affecting cartilage may result in serious infections. There have been many reports of chondritis, perichondritis, and subperichondral abscesses caused by Pseudomonas aeruginosa following ear piercings that involve aural cartilage.4–7 Frequently, surgical drainage, debridement, or resection is required. Resultant permanent deformity of the pinna has been reported.

Oral and nasal piercings present unique infection risks due to communication with colonized mucus membranes. Infections associated with oral piercings include lingual abscess, Ludwig's angina, endocarditis, and brain abscess.8–10

Nipple piercings have resulted in mastitis11 and infection of a breast implant.12 Because navel piercings can take up to two years to fully heal, they are at protracted risk for localized wound infection.

It has been suggested than genital metal jewelry involving the male urethra may be protective against chlamydia.13 One study found no association between body piercing and genital infections,14 but there is concern that genital piercings may increase transmission of sexually transmitted diseases by damaging condoms or abrading mucosal surfaces.



Tattoo or body piercing instruments or dyes that are used on more than one person offer the potential risk of bloodborne infection. Transmission of both syphilis and hepatitis B virus (HBV) has been reported as a complication of tattoos and body piercing. Most studies support the contention that body piercing is an independent risk factor for hepatitis.15 A recent study found tattoos from a commercial tattoo parlor to be an independent risk factor for hepatitis C virus (HCV) (OR=6.5; 95% CI=2.9–14.8).16 Piercing and tattooing have been implicated in HIV transmission.17,18 While not proven, this is no doubt possible.

Systemic infections caused by body art include staphylococcal toxic shock syndrome, Group A beta hemolytic streptococcus septicemia, and tetanus

Tattoos have been rarely associated with the transmission of molluscum contagiosum19 and sporotrichosis.20 There have been several reports of verruca vulgaris inoculation in the tattoo pattern.21–23 Systemic infections caused by body art include staphylococcal toxic shock syndrome,24 Group A beta hemolytic streptococcus septicemia,25 and tetanus.26 Endocarditis secondary to piercing27 and tattooing28 has been reported in patients with bicuspid aortic valves. An asplenic patient developed Candida endophthalmitis after tattooing.29

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Treatment and Prevention

Local infection should be treated with antistaphylococcal antibiotics. Initially the jewelry should be left in place to provide drainage and preserve the pierced tract. The piercing should be cleansed and rotated twice daily with clean or gloved hands and sea-salt water or a water-soluble mild liquid antimicrobial soap. Occlusive ointments should be avoided.30

The patient should be re-assessed at 24 to 48 hours. If the infection is not improving, the jewelry should be removed for debridement and drainage. Intravenous antibiotics and hospital admission may be necessary depending on the extent and location of the infection and the underlying medical condition of the patient.

While a similar initial approach can be utilized for cellulitis associated with high ear piercings, perichondritis must be ruled out. While cellulitis commonly presents in the first few days after piercing, complications involving the cartilage generally do not develop until somewhat later.



Perichondritis is generally more painful than uncomplicated cellulitis, but the key to diagnosis is subperichondral fluid. This is evidenced by fluctuance, which may be a subtle finding. This fluid prevents perfusion of the cartilage, and chondral ischemia, calcification, and permanent deformity can develop rapidly. The jewelry should be removed, anti-pseudomonal antibiotics prescribed, and urgent ENT or plastic surgery referral obtained. Surgical treatment includes drainage of the subperichondral fluid from one or both sides and the placement of compressive bolsters to prevent reaccumulation of fluid. Evidence of distant or systemic infection must be sought and treated appropriately and aggressively.

Strict aseptic technique helps prevent transmission of bloodborne pathogens. Most states have enacted or are developing legislation to regulate commercial tattoo and piercing activities. Adherence to these standards may essentially eliminate the infectious risks of professional tattoos.

Body piercing, however, leads to risks beyond those incurred at the time of the procedure. A foreign body remains in a slow-healing wound. Proper after-care, described at the Association of Professional Piercers web site (, may significantly decrease the incidence of infection.

Prophylactic antibiotics to prevent endocarditis in susceptible individuals are currently not officially recommended for tattooing or body piercing. Patients with valvular heart disease, asplenia, or other risk factors should be aware of the dangers associated with body art.

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  • ▪ Body art is a risk for significant local and bloodstream infections.
  • ▪ Infected piercings should initially be treated with anti-staphylococcal antibiotics with the jewelry left in place.
  • ▪ Treatment failure may necessitate jewelry removal and surgical care.
  • ▪ High ear piercings can lead to severe pseudomonal cartilage infections. Suspected chondritis should prompt urgent jewelry removal, aggressive antibiotic therapy, and urgent follow-up with a specialist.
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© 2002 Lippincott Williams & Wilkins, Inc.