CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

AdolescentCora C. Breuner, MD, MPH,a​ David A.and Levine, MD, b​ YoungTHE COMMITTEE ON ADOLESCENCEAdult Tattooing, Piercing, and Scarification Tattoos, piercing, and scarification are now commonplace among abstract adolescents and young adults. This first clinical report from the American Academy of Pediatrics on voluntary body modification will review the methods used to perform the modifications. Complications resulting from body modification methods, although not common, are discussed to provide aAdolescent Medicine Division, Department of Pediatrics, Orthopedics the pediatrician with management information. Body modification will be and Sports Medicine, Seattle Children’s Hospital, University of Washington, Seattle, Washington; and bPediatrics, Morehouse School of contrasted with nonsuicidal self-injury. When available, information also is Medicine, Atlanta, Georgia presented on societal perceptions of body modification. State laws are subject to change, and other state laws and regulations may impact the interpretation of this listing.

Drs Breuner and Levine shared responsibility for all aspects of writing and editing the document and reviewing and responding to questions and comments from reviewers and the Board of Directors, and “ ” approve the final manuscript as submitted. This document is copyrighted and is property of the American Tattoos, piercings, and scarification, also known as body modifications,​ Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy are commonly obtained by adolescents and young adults. Previous of Pediatrics. Any conflicts have been resolved through a process reports on those who obtain tattoos, piercings, and scarification have 1 approved by the Board of Directors. The American Academy of – Pediatrics has neither solicited nor accepted any commercial focused mainly on high-risk populations, including at-risk adolescents. involvement in the development of the content of this publication. Tattooing and piercing of various body parts no longer is a high-risk Clinical reports from the American Academy of Pediatrics benefit from population phenomenon, as evidenced by growing numbers of adults and expertise and resources of liaisons and internal (AAP) and external adolescents not considered at risk who have tattoos and multiple ear and reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations body piercings. The Pew Research Center reports that in 2010, 38% of or government agencies that they represent. 18 to 29 year olds had at least 1 tattoo, and 23% had piercings in locations 2 The guidance in this report does not indicate an exclusive course of other than2 an earlobe. Of those with tattoos, 72% were covered and not treatment or serve as a standard of medical care. Variations, taking visible. Scarification is the practice of intentionally irritating the skin to into account individual circumstances, may be appropriate. cause a permanent pattern of scar tissue; data are not currently available All clinical reports from the American Academy of Pediatrics on the prevalence of scarification in the United States. automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Although body modifications have become a mainstream trend, DOI: https://​doi.​org/​10.​1542/​peds.​2017-​1962 they still may be associated with medical complications and, among Address correspondence to Cora C. Breuner, MD, MPH, FAAP. E-mail: adolescents, may also co-occur with high-risk behaviors. This first [email protected] clinical report from the American Academy of Pediatrics on tattooing, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). piercing, and scarification discusses the history of these methods of body modification, educates the reader on methods used, reports on trends in associated adolescent and young adult risk behaviors, differentiates To cite: Breuner CC, Levine DA, AAP THE COMMITTEE ON between nonsuicidal self-injury (NSSI) and body modifications, and ADOLESCENCE. Adolescent and Young Adult Tattooing, Piercing, educates the reader about how to anticipate and prevent potential and Scarification. Pediatrics. 2017;140(4):e20171962 medical complications. The report analyzes the literature about societal acceptance of people with body modifications and perceptions that Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 140, number 4, October 2017:e20171962 From the American Academy of Pediatrics

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF ’ ’ might potentially interfere with probability sample of adults found by navel (38%), tongue (13%), and

adolescents and young adults higher tattoo rates among4 younger nipple and genital (9%) piercings. educational and career plans. Finally, versus older cohorts. Evidence on guidance is provided to pediatricians sex differences in tattooing also A survey conducted among college and, through the pediatrician, to varies, with tattoo prevalence among freshmen from Italy found that many parents and adolescents and young women ranging from 22% to 23% students undergoing tattooing and/ or piercing were unaware12 of the adults about safety and regulations and prevalence among4,6​ men ranging regarding body modification should from 19% to 26%. ‍ Among those associated health risks. Although they wish to obtain tattoos, piercings, with a tattoo, most (86%) have most (60%) students knew about or scarification. never regretted getting one, and HIV-related risks, less than half knew about possible infection History of Body Modification: 30% said it makes them feel sexier. Tattooing, Piercing, and Other feelings attributed to having with hepatitis C (38%), hepatitis Scarification a tattoo included feeling rebellious B (34%), tetanus (34%), or about 12 (25%), attractive or strong (21%), noninfectious complications (28%). spiritual (16%), healthier (9%), more These findings have similarly been 6 reported in a sample of medical Although interest in body intelligent (8%), and athletic (5%). students who had undergone modification has increased 13 piercing. recently, history teaches us that Estimates of tattooing and piercing body modifications are not new. among adolescents range by data Scarification is the practice of Archeologists have found evidence of source and age group. One early intentionally irritating the skin to tattoos, piercings, and scarification as study among high school students cause a permanent pattern of scar far back as 2000 BC, when they were from 8 states found that 10% had tissue. Studies have been conducted largely used as a form of art or to tattoos, and 755% expressed interest among international communities identify group membership, such as in tattooing. In this sample, tattoos describing high rates of scarification, a religious group or tribe. Although were commonly obtained around the yet no studies on scarification have mostly used to describe loyalty, ninth grade, but there were reports7 been reported14,15​ from the United interests, and lifestyle choices, body of tattooing as early as age 8 years. States. ‍ In the 1990s and 2000s, Among adolescent clinic samples of modification had also been used to 3 there was some renewed interest in label criminals, slaves, and convicts. youth 12 to 22 years of age, tattooing scarification as a movement to revive ranged from 10% to 23%, and body Although in the late 20th century, indigenous rituals from around the piercing (other than the earlobe)8,9​ most tattoos were on men, ranging world, embracing a more authentic16 ranged from 27% to 42%,​ ‍ with or spiritual body experience. from the stereotypical tattooed higher rates of tattooing and body sailors and motorcycle bikers (eg, piercing among girls versus boys and Declining Strength of 8,9​ Associations With Risk Behaviors The Hells Angels in the 1960s) older versus younger adolescents. ‍ to 1980s gang members, now, Harris Poll data revealed that 22% of tattoos are collections of colorful youth 18 to 24 years6 of age reported ornamentations for both women and having a tattoo,​ but estimates were Although in the past, body men. Surveys of the US population as high as 38% among young people modification was often associated have shown an increase in the 4,5​ 18 to 29 years of age on the basis2 of with adolescent high-risk behaviors, prevalence of tattoos over time. ‍ Pew Research Center findings. current data have not consistently Epidemiology reported this association. In a Findings are comparable among retrospective analysis from 2007 to subsequent samples of private 2008, tattoos were associated with Harris Poll data from 2016 found that university and college students, of alcohol and drug use, violence and

3 in 10 US adults had at6 least 1 tattoo, whom 23% had 10,a tattoo11​ and 51% had weapons carrying, sexual activity,17 up from 20% in 2012. Differences a body piercing. ‍ Male athletes eating disorders, and suicide. were found by geographic region, were more likely to be tattooed However, the scientific link between

with tattoos being more prevalent than male nonathletes, and although tattooing and risk behaviors1 is in the West (27%) versus the East women were more likely to have less consistent today. As with any

(28%),6 Midwest (27%), and South a piercing than men, there was10, no11​ adolescent or young adult, for those (32%). Tattoos were also more difference by sex for tattooing. ‍ Of with piercings and tattoos, it is prevalent among adults in their 30s students with current piercings, high- advised that the pediatrician conduct

compared6 with those younger and ear cartilage (53%) was the most a careful adolescent psychosocial older,​ although another national common visible piercing, followed history with targeted behavioral Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF interventions to18 assist in decreasing among those with and without modification may be well advised to risk behaviors. tattoos, 29% believed that people make sure that the tattoo or piercing Body Modification Is Not NSSI with tattoos were more likely to do is not visible in typical work attire. something most people consider Tattooing deviant, whereas 24% believed 6 Methods It is important to be able to this in 2012. From another survey distinguish normal body modification regarding technological and social from body modification that is changes, 40% of respondents said A multitude of videos on YouTube more dramatic or intense as part of that more people getting tattoos has Diagnostic and Statistical and other Internet video repositories NSSI syndrome, which is described been a change for the worse, 45% Manual of Mental Disorders, Fifth exist for the reader to view and learn in the of respondents said that it has made Edition “ no difference, and only 7% said this about safe and acceptable methods of tattoo placement. After selecting as follows: over the past has been a change for the better. As or designing the art to be transferred year, the person has for at least 5 might be expected, older Americans via tattoo, it is stenciled or drawn days engaged in self-injury with the are far more likely to negatively view on the skin. The skin is cleansed anticipation that the injury will result this trend; 64% of those 65 years ” with antiseptic, and a thin layer of in some bodily harm without suicidal and older and 51% of those 50 to 19 ointment (such as petroleum jelly) intent. ‍ 64 years of age said more people is placed on the site. Professional getting tattoos has been a change – NSSI differs from body modification for the worse. A majority of those tattoo artists use a motorized, because NSSI often is impulsive or younger than 50 years (56%) said the electric powered machine that holds compulsive and may be associated needles and can puncture the skin tattoo trend22 has not made much of a with mental health disorders, difference. up to several thousand times per including psychotic disorders, minute. The needles are dipped into The age differences are larger among personality20 disorders, and anxiety ∼ the ink and then puncture the skin at disorders. Estimated prevalence women than men. Of women aged a depth of a few millimeters, where rates for NSSI in 2008 for adolescents 50 years and older, 6 in 10 (61%) the pigment reaches the dermis layer. were between 14% and 24%. It can said more people getting tattoos Any blood or serosanguineous fluid include cutting, scratching, burning, have been a change for the worse, is wiped away during the procedure. and hitting oneself. Individuals who compared with 27% of younger After completion, another antiseptic hurt themselves report injuries21 to women. The gap is smaller among is applied, and the tattoo is covered. many different body parts. The men; 51% of men aged 50 years After 24 hours, the dressing is individual who engages in self-injury and older said more people getting removed and the tattoo remains open expects to get relief from a negative tattoos has been a change for the to air, and the skin is kept moist by emotion, deal with a personal19 issue, worse, compared2 with 30% of applying antibiotic ointments, thick or create a positive feeling. younger men. skin cream, or vitamin E oil several Importantly, NSSI is clinically Although societal acceptance of times daily. If cleansing is necessary, concerning because of an association tattoos and piercings has increased, the skin is blotted and not rubbed. with mental health disorders, there still may be repercussions Tattoos generally take 2 weeks to whereas body modification such when seeking employment or heal; sun exposure should be avoided as tattooing, piercing, and/or educational opportunities. In a or sunscreen should be used, and scarification does not have these 2014 survey of nearly 2700 people, swimming, direct shower jets, or soaking in water should be avoided. associations19 and is more socially 76% thought that tattoos and/or acceptable. Intention is the most piercings had hurt their chances Clothing that might adhere to the3 important differentiator and can of getting a job, and 39% thought tattoo site should not be worn.

be discerned 18with careful clinical employees with tattoos and/or The inks of tattoos are a mixture interviewing. piercings reflect23 poorly on their of inorganic and synthetic organic Perceptions of Community and employers. One executive career pigments and diluents. They are Potential Employers About coach wrote that 37% of human considered cosmetics by the US Tattooing and Piercing resource managers cite tattoos as the Food and Drug Administration. third physical attribute likely to limit Metal salts are commonly used as

career potential (nonear piercings24,25​ pigments; aluminum, cadmium, Public opinion of the relationship and bad breath were the top 2). ‍ chromium, cobalt, iron, mercury, between having a tattoo and deviant Consequently, adolescents and nickel, silicon, and titanium are behavior is changing. In 2008, young adults contemplating body a few of the metallic elements in Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 140, number 4, October 2017 3

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF 26 tattoo pigments. Although the The method of tattooing is similar to pruritus, papules, or nodules at the concentration of metals in tattoo ink whatHenna is and discussed Temporary previously. Tattoos site. Pathologically, the reactions is low, metals are emerging as a class include lichenoid, eczematoid, of human carcinogens. Cutaneous sarcoidal, and pseudolymphomatous exposure over a lifetime may result The henna plant contains the pigment reactions as well as foreign-body in adverse events. Risk is modified lawsone; in the skin, it interacts with granulomas. Preexisting conditions “ ” by bioavailability, cellular uptake, keratin to give a reddish-brown color can lead to other reactions; psoriasis, “ ” metal interactions, protein binding, (sometimes known as red henna to systemic lupus, and sarcoidosis bone sequestration, and excretion. distinguish from black henna,​ may demonstrate the Koebner Age, sex, genetic variance, and other which is red henna mixed with phenomenon, leading to new factors also appear27 to influence paraphenylenediamine [PPD]). Red lesions at the site of the tattoo. potential toxicity. henna is commonly used in Islamic Even temporary henna tattoos have and Hindu societies, especially for been associated with inflammatory Unfortunately, many tattoos are 31 celebrations such as weddings and reactions. placed by amateurs, which makes religious ceremonies. The henna the process much riskier. In these powder is mixed with a variety of Infections are a potentially more cases, antiseptic processes may not materials depending on the artist serious complication of tattooing. be followed, leading to potential and the region. They may include Tattooing can lead to infection skin infections and transmission essential oils, such as lemon or caused by contaminated tattoo ink of bloodborne illnesses, such as eucalyptus, the dried powder of or needles; inadequate disinfection hepatitis C or HIV. Prison tattooing is indigo plant leaves, lemon or beet usually painful because of the use of of the skin to be tattooed, resulting root juice, tannin from tea leaves, typically blunt instruments that are in resident bacterial contamination dried coffee, charcoal powder, available. The generally poor quality during the tattooing process; and, turpentine, PPD (discussed later), and obvious visual location tends to secondarily, during the healing or even animal urine. Henna also stigmatize prisoners on release and process, when32 injured tissue causes has been used in different ways for may limit their chances of obtaining pruritus. Unfortunately, the real medicinal purposes beyond the scope employment (see the previous 30 frequency of local infections after of this report. tattooing is unknown. Infections section about public and28 employer perceptions as well). The pigments The paste is applied to the skin may be superficial pyogenic are not standardized and may also and remains for 30 minutes to 6 infections, deep or severe pyogenic hours; the longer the exposure, the infections, atypical mycobacterial contain more toxic27 materials as well as contamination. darker the color. At that point, there infections, systemic or cutaneous Permanent Makeup will be an orange stain, which will viral infections, or (rarely) cutaneous darken over the next 2 to 4 days. A fungal infections. Systemic viral temporary tattoo will usually last for infections from bloodborne Permanent makeup has become 2 to 6 weeks, until30 the outer layer of pathogens include hepatitis C, an increasingly popular form of Cskinomplications exfoliates. hepatitis B,Staphylococcus and HIV. Superficial aureus tattooing. Permanent makeup pyogenicStreptococcus infections pyogenes are usually advertisers talk about the advantages related to of being waterproof, not smearing, The rate of complications from or , with time saving, and hassle free. Some having tattoos placed is not known. common patterns of pustules or people choose permanent makeup However, with the large number papulopustules along the tattoo because of physical limitations, such of tattoos placed every day and lines. Infections are typically as visual impairments or arthritis few reports of complications from present 4 to 22 days after tattooing. of the hands or shoulders. Cosmetic clients who receive tattoos, the rate Infections range from cellulitis and tattooing can also be an adjunctive is likely low. Most of the relevant small pustules to larger abscesses to reconstructive surgery, such medical literature are case reports or that require surgical incision and as nipple reconstruction after a reports of local clusters of infection. drainage. Management is similar mastectomy or breast reduction Reported complications of tattoos are to other skin pyogenic infections. surgery. It is also used to cover inflammation, infections (bacterial More severe pyogenic infections scars, birthmarks, alopecia, and and viral), neoplasms, and rare remain rare, but there are case vitiligo. Cosmetic tattooing also may reports of vasculitis. Inflammation reports of endocarditis, spinal

be attractive to patients who have 29 is caused by sensitivity to tattoo abscess, erysipelas,33 gangrene, and allergies to conventional cosmetics. pigments leading to focal edema, amputations. Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF There are many case reports than if they 41are placed by unlicensed The structure and redox potential of of patients who have acquired individuals. lawsone is similar to naphthalene, nontuberculous mycobacteria (NTM)34,35​ There have been case reports of a potent oxidant of glucose-6- infections after receiving tattoos. ‍ neoplasms associated with or after dehydrogenase (G6PD)-deficient The infection usually is caused tattoo placement. Keratoacanthoma, cells. Topical application of red henna by contaminationMycobacterium of the ink or 36 squamous cell carcinoma, basal cell may cause hemolysis in children with equipmentchelonae withMycobacterium nonsterile water . carcinoma, and leiomyosarcoma have G6PD deficiency. The hemolysis can abscessusInfections with been described occurring in areas of be life threatening, with symptoms and the skin with tattoo pigmentation. of pallor, lethargy, jaundice, , which are rapidly growing It is not known whether this is a anemia, vomiting, tachycardia, poor30 bacteria, have occurred from the coincidence or a causal effect. Tattoos peripheral perfusion, and shock. contamination of either inks or placed over melanocytic nevi can Black henna contains the chemical diluents. NTM infections range from make it difficult to monitor to ensure PPD. No natural black henna exists. mild inflammation with lesional there is no malignant transformation, PPD is added to accelerate the dyeing rash, papules, or nodules to severe é and both nevi and melanoma have and drying process (to 30 minutes), abscesses requiring extensive and been31 reported in previously tattooed to strengthen and darken the color, to multiple surgical d bridements. skin. enhance the design, and to make the NTM infections may require a pattern last longer. These methods minimum of 4 weeks of treatment Rarely, there have been cases 36 stain the skin black and have an with 2 or more antibiotic agents. reported of acute cutaneous appearance more like a real tattoo. Examples of antibiotic agents that vasculitis in tattoo recipients Black henna is available worldwide, have been used, with variable success occurring 10 to 14 days after lasts several weeks in the skin, and and sensitivities, are amikacin, placement. The following symptoms offers an alternative to permanent ciprofloxacin and moxifloxacin, were typical: chills, arthralgia, tattoos. It is painless, and because the clarithromycin, minocycline, myalgia, and purpuric rash. skin is not punctured, there is no risk tigecycline, cefoxitin, imipenem, Treatment is similar 33to the treatment of introducing local or bloodborne trimethoprim-sulfamethoxazole, of other vasculitides. 35 pathogens. However, there is a slight and linezolid. Antibiotic sensitivity Researchers in one review article (2.5%) risk of allergic reactions from is important in designing a discuss toxicologic risks of tattoo ink, 37 skin sensitization. Once sensitized, treatment plan. Consultation with including phototoxicity, substance patients may experience allergic an infectious disease expert for migration, and the possible metabolic contact dermatitis from hair dyes suspected NTM infection in a tattoo is conversion of tattoo ink ingredients. that contain PPD. There are also warranted. Herpes Also reviewed are the potential risks reported cross-reactions to other hair compuncturum associated with cleavage products Another case report described dyes, dyes used in textiles, rubber formed during laser-assisted tattoo that developed 3 days 42 chemicals, and local anesthetics. Hennaremoval and. Black Henna Temporary after tattooing; it was concluded that S aureus Tattoos Some reported reactions were this was a secondary infection in a severe, requiring hospitalizations, patient in whom also was especially in children. Most reactions detected. Antibiotic therapy, antiviral were at the site, but generalization Red henna is relatively safe. From a therapy, and pain management can occur. It takes several weeks for 33 population perspective, at least half resolved the rash. reactions to subside despite topical of the population of India has been and sometimes oral corticosteroid Bloodborne pathogens may exposed to henna in their lifetimes 30 Tattootherapy R.emoval occur after tattooing. Tattooing with negligible reported immediate43 is associated with hepatitis B hypersensitivity reactions. When

transmission, especially in teenagers38 they have occurred, it is not certain with other high-risk behaviors. whether sensitivity is caused by The current increasing popularity Tattooing also is associated the lawsone pigment, another of tattoos in the United States has

with higher rates39 of hepatitis C component of the henna leaf, or concomitantly spurred an increased transmission. HIV transmission the mixture of components. There interest in tattoo removal, although associated with sharing tattoo is more concern for hairdressers tattoo removal is not new. Egyptian

needles or reusing40 tattoo inks has who use henna in dyes because 30it mummies dating to 4000 BC have been reported. If tattoos are placed may be an occupational hazard. evidence of attempted tattoo in licensed parlors, infections are Treatment is similar to that of other removal. Ancient Greek authors less likely to occur after tattooing hypersensitivity reactions. described the use of salt abrasion Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 140, number 4, October 2017 5

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF or a paste that also contained garlic described in a report, the patient of body piercing, some of which

and cantharidin to remove tattoos. elected to have another 47tattoo placed take the observer through the steps, Relationships, social status, and to hide the burned area. including infection control practices. aesthetic tastes may change. Not Most body piercing jewelry consists Other methods that are less all tattoos are placed intentionally; of rings, hoops, studs, or barbell- commonly used for tattoo removal penetration of exogenous pigments shaped ornaments. The size and include mechanical and chemical can occur from road dirt from an shape of jewelry is determined by removal techniques. Mechanical accident, graphite in pencils, or the body site pierced and personal methods include dermabrasion gunpowder, and many people may preferences. Jewelry is not always (which is variably effective) and want these unintentional tattoos interchangeable between piercing 44 excision with or without grafting removed. Adolescents may sites. In particular, jewelry designed (mostly for small tattoos; the overestimate the effectiveness of for ear piercing may not be suitable predicted scar remaining would tattoo removal when having one for another part of the body because have to be acceptable to the patient). placed and should be instructed that of the length of the post or the A number of chemical methods 50 tattoo placement is permanent, and it pressure exerted by the clasp. have been used with dermabrasion is expensive and sometimes difficult 3 or as monotherapy. Imiquimod Most body piercing jewelry is made to remove them. Tattoo removal has been applied, with or without of metal, usually stainless steel, gold, techniques can be categorized as tretinoin, with mixed results. These niobium, titanium, or alloys. Gold mechanical, chemical, ablative, and 44 techniques often result in hypo- or often is combined with nickel or selective. “ ” hyperpigmentation, or44 scarring, with other metals to make alloys that have varying effectiveness. improved hardness and durability. Q-switched lasers are the current Nickel in gold-filled or gold-plated state-of-the-art tattoo removal Although laser removal may be the jewelry is associated with a high method. The laser wavelength is best way to remove a tattoo, the time, prevalence of reactivity in people adjusted to match the absorption needed treatments, and cost should who are nickel sensitive. Those pattern of the different color not be underestimated. One case who are getting a piercing should pigments. The Q-switched laser report noted a 29 year old patient pay careful attention to the studs or pulse is delivered over nanoseconds with 2 large, multicolored tattoos on ° ° clasps on earrings; jewelry with a with extremely rapid heating as his arms and chest who presented for high karat rating commonly is paired high as 900 C (1652 F), leading to removal. After 47 treatments, there 48 with less expensive gold-plated fragmentation of tattoo pigment was significant improvement. There studs or earring backs. Niobium and particles. Immediately after the is no cost regulation of laser tattoo titanium are light-weight elemental pulse, the epidermis appears white removal, and price per sq in per metals that rarely produce an because the formation of gas as water treatment can be anywhere between allergic response. Other features to in the skin is vaporized. An acute $49 and $300 depending on the consider in body piercing jewelry inflammatory infiltrate surrounds location of the removal service. There include the ease of removal (in case the pigment and debris from are also standards published that of trauma or radiographs), surface fragmented cells. Tattoo particles involve the skin type and complexion smoothness, and its capacity to can be found in regional lymph of the individual, the colors involved, 51 withstand autoclaving and cleaning. nodes. Phagocytosis and clearance and complexity of the pattern adding Surgical stainless steel rarely causes of fragmented pigment particles up to a clinical score known as the allergic skin reactions; however, not ensues. Free pigment is intracellular Kirby-Desai score. A tattoo that is all stainless-steel products are nickel again within 4 weeks. Subsequent 15 sq in and is estimated to have 8 52 free. treatment should be performed after sessions based on this Kirby-Desai at least 4 weeks. One single-session score could cost $5880,49 assuming a Although earrings may be sterilized laser treatment is available. Longer cost of $49 per sq in. before use, most piercing guns are intervals may reduce the risk of Piercing and Stretching not sterilized between procedures.

permanent44,45​ pigmentary changes to Ear piercing systems using Methods the skin. ‍ It is important to have disposable, sterile cassettes are 51 the requisite training in the use of the available but are not always used. Q-switched laser for tattoo removal; Because body piercing salons are the literature notes case reports A multitude of videos on YouTube unregulated in many states, some of significant burns within tattoos and other Internet video repositories physicians may choose to perform

after treatment, leading46 to scarring exist for the reader to view and learn body piercing procedures in their and poor outcomes. In one case about safe and acceptable methods own office settings. Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF TABLE 1 Approximate Healing Times for Body Piercing Sites51 The lips, cheeks, and midline of the Site (Piercing Name) Time to Heal to more severe infections, including tongue are popular sites for oral osteomyelitis, toxic shock syndrome, Clitoris 2 6 wk piercings. Perforation of lingual – and bacteremia. Life-threatening Coronal ridge (dydoe) 6–8 wk blood vessels can cause bleeding Earlobe and auricle 6–8 wk infections as a result of complications and hematoma formation. Edema Eyebrow 6–8 wk associated with body piercing include frequently develops after a tongue Glans penis (ampallang) 3–9 mo septic arthritis, endocarditis, and piercing, so a longer barbell is Labia majora 2–4 mo hepatitis B. With any piercing, there 53 Labia minora 2 6 wk recommended initially. Switching – is the danger of infection, including Lip 6–8 wk 41,61​ to a shorter barbell reduces the Navel Up to 9 mo hepatitis B or C virus and tetanus. ‍ damage to the dentition and gingiva. Nipple 2–4 mo Body piercing as a possible vector Of note, beaded jewelry may become Scrotum (hafada) 2–3 mo for HIV transmission has been Tongue 3–6 wk trapped between the teeth. suggested, although62,63​ no cases have Urethral meatus (Prince 2–4 wk The ear is the most universal site for Albert) been reported. ‍ body piercing. Multiple ear piercings have gained approval, especially A serious consequence of oral high piercing through the cartilage piercing is airway compromise from trauma, tongue swelling, or of the pinna. The nose can be pierced piercing, is defined as piercings 64 obstruction by jewelry. Securing in the fleshy nares or through placed into a flat surface of the body. an adequate airway or endotracheal the cartilaginous septum. Septal The jewelry has an entry point and intubation can be challenging when piercings usually are performed in an exit point, but dermal piercing has 57,65​ a patient has a tongue barbell. ‍ If the inferior, fleshy part of the septum just one end that can be seen on the lingual jewelry cannot be removed and not through cartilaginous tissue. surface of the skin. The second end easily or expeditiously, precautions The navel or periumbilical area is a is studded into the dermal layer of should be taken during intubation to popular self-piercing site. Navel rings the skin. This variant of piercing has ensure that jewelry is not loosened and subsequent scarring are more gained a lot of popularity because it and aspirated or swallowed. Removal problematic in overweight patients can be placed on most flat surfaces of of oral and nasal jewelry also is and in the latter stages of pregnancy the body, and designs can be created recommended before nonemergency as abdominal girth expands. by putting together multiple dermal surgical procedures. Chipping piercings or combining with tattoos. Wearing a curved barbell instead or fracturing of teeth is the most They may be difficult to remove and of a ring until the navel piercing common dental problem related to may occasionally require surgical 66 has healed may reduce irritation 55,56​ tongue barbells. and scarring. Friction from clothing Cremovalomplications. ‍ with tight-fitting waistbands and Although there is a risk of infection subsequent skin maceration may because of the vast amounts account for the delayed healing No reliable estimates are available of bacteria in the mouth, the and increased infection rates of regarding people who have infection rate is low. Oral rinses navel piercings. Careful placement experienced complications related (eg, Listerine; Johnson and Johnson of jewelry and avoidance of rigidly to body piercing. Importantly, Consumer Companies Inc, New fixed jewelry may minimize these adolescents and young adults with Brunswick, NJ) or the application problems. Before nipple and areolae increased vulnerability to infection of nonprescription cleansers (eg, piercings, men and women should (eg, patients with diabetes mellitus Gly-Oxide Liquid Antiseptic Oral be counseled about the lengthy time or who are taking corticosteroids) Cleanser; GlaxoSmithKline Consumer required for complete healing and the and those taking anticoagulant Healthcare, Philadelphia, PA) may be risk of delayed infection (see Table 1). medications may be at greater risk recommended prophylactically67 after Genital piercings anecdotally have of complications from body piercing. an oral piercing. been reported to enhance sexual However, multiple adverse outcomes sensitivity. Genital piercing sites in associated with body piercing have Ludwig angina is a rapidly spreading men include the penile glans, urethra, been reported, including infection, oral cellulitis and has been reported foreskin, and scrotum; sites in pain, bleeding, hematoma formation, as a complication68 of tongue women include the clitoral prepuce cyst formation,– allergic reaction, piercing. Treatment involves hypertrophic scarring, and keloid or body, labia minora,54 labia majora, 51,57​ 60 maintaining an adequate airway, the and perineum. formation. ‍ ‍ administration of systemic antibiotic Dermal piercing, also known as Infection severity ranges from local agents, and surgical drainage of microdermal piercing or single-point infections (impetigo and cellulitis) abscesses. Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 140, number 4, October 2017 7

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF 79 Of people with ear piercings, up to Johnson Consumer Companies Inc, heals. Similarly, a loop fashioned 35% had one or more complication New Brunswick, NJ]). Treatment from nylon suture material may keep (eg, minor infection [77%], allergic with mupirocin ointment or oral a piercing intact during the healing

reaction [43%], keloid formation antistaphylococcal 61antibiotic agents process. [2.5%], and69 traumatic tearing may be warranted. Oral antibiotic [2.5%]). Auricular perichondritis agents, such as the first-generation Earrings can also become embedded and perichondrial abscess typically cephalosporins (eg, cephalexin in the earlobe, a complication occur in the first month after or cefadroxil and penicillinase- common in persons with thick, fleshy earlobes that are pierced piercing, especially70 during warm- resistant penicillins), are appropriate 80 weather months. treatment options for more extensive with spring-loaded guns. Piercing but uncomplicated skin and soft guns exert high pressure on the soft Auricular perichondritis presents tissue infections. Alternative tissue of the earlobe and cannot be as painful swelling, warmth, and antibiotic agents (ie, clindamycin or adjusted for varying tissue thickness. redness in a portion of the auricle trimethoprim-sulfamethoxazole) may Embedding may be prevented by that often spares the earlobe. be more appropriate in communities using longer earring posts with Acute tenderness on deflecting S aureus that have higher rates of methicillin- adjustable backings. If gentle probing the auricular cartilage helps resistant cases. Guidelines fails to locate an embedded earring, a distinguish this deeper perichondrial S aureus for the treatment of methicillin- small incision under local anesthesia infection from a superficial skin resistant , according to (without epinephrine) may be infection. Minor infections can the Infectious Diseases Society of necessary to locate and remove the progress to perichondritis, abscess America, also suggest doxycycline or earring or backing. Any suspected80 formation, and necrosis with or 74 linezolid might also be appropriate. infection should be treated. without systemic symptoms. The Pseudomonas aeruginosa S aureus An earring can be replaced, or the most common pathogens (ie, Trauma to the pierced external ear S pyogenes ear can be repierced 6 to 8 weeks , , is common. Lacerations to the ear after resolution of local swelling and and ) often respond 51 may occur after falls, motor vehicle tenderness. well to fluoroquinolone antibiotic crashes, contact sports, person-to- treatment (eg,71, ciprofloxacin72​ or The earlobe is a common site for person violence, or accidental pulling levofloxacin). ‍ Alternative options hypertrophic scarring and keloid of an earring. The simplest laceration for hospitalization will depend on formation. In addition to aesthetic occurs when an earring is pulled the pathogen and might include concerns, patients with keloids through the earlobe, especially if the clindamycin, ceftazidime, and may have itching and tenderness. original earring hole was close to cefepime. Treatment options for keloids include the periphery. All wounds should be surgical excision, intralesional If an abscess is present, surgical cleaned and repaired within 12 to 24 corticosteroid injections, incision and drainage often are hours. A simple earlobe tear can be cryosurgery, pressure dressing, necessary. Once an abscess develops, 75,76​ sutured under local anesthesia. If the radiation, and laser therapy. ‍ hole has closed, the earlobe can be good cosmetic preservation of the ∼ auricular cartilage is difficult to Contact dermatitis resulting from repierced in81 an unscarred area after maintain. nickel exposure is common. Contact 3 months. sensitivity to gold and localized Prolonged wearing of heavy jewelry Various closure techniques have been argyria, a skin discoloration resulting also may result in an elongated tract described in the literature. More from silver salts, also have been or bifid deformity of the earlobe. 77,78​ complex lacerations of ear cartilage described. ‍ Avoidance of the should be referred to subspecialists People with atopic dermatitis or metals that trigger a reaction and the 82 for repair. allergic metal contact dermatitis are application of topical corticosteroids at increased risk of developing minor hasten the resolution of allergic Pointed earring posts may cause staphylococcal or streptococcal skin 73 dermatitis. pressure sores or postauricular skin infections. Occasionally, inflammation or irritation when worn during sleep. Superficial earlobe infections tend infection result in such significant The removal of jewelry at bedtime is to have a benign course and respond swelling that an earring should be indicated if switching to a different well to local treatment, including removed. The pierced hole can be earring style does not resolve the warm, moist packs and application of maintained, if desired, by inserting problem. Parents of infants or young over-the-counter, topical antibiotic a ring made from a 20-gauge Teflon children with pierced ears should be ointment (eg, bacitracin [Polysporin catheter with silicone tubing into informed of the risk of aspiration and and Neosporin; Johnson and the hole while the surrounding skin ingestion of earring parts. In such Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF TABLE 2 Potential Complications of Body Piercings51 Piercing Site Potential Complications situations, earrings with a locking83 back or screw back are advisable. Ear Allergic reaction, auricular perichondritis, embedded earrings, infection, keloid formation, perichondral abscess, and traumatic tear A localized infection of the earlobe Genitals (women) Allergic reaction, compromise of barrier contraceptives, infection, and keloid may not be easily differentiated from formation Genitals (men) Frictional irritation, infection, paraphimosis, penile engorgement, priapism, allergic contact dermatitis unless recurrent condyloma, urethral rupture, urethral stricture, and urinary flow there is purulent drainage78 or a high interruption index of suspicion. Mouth Airway compromise, altered eating habits, gingival trauma, hematoma formation, increased salivary flow, infection, injury to salivary glands, Piercing the nasal cartilage can cause interference with radiographs, loss of taste, Ludwig angina, pain, significant bleeding and lead to septal permanent numbness, speech impediments, tooth fracture or chipping, and hematoma formation that often is uncontrolled drooling accompanied by infection. Other Navel Bacterial endocarditisa, frictional irritation, infection, and jewelry migration potential complications that may and rejection Nipples Abscess formation, bacterial endocarditisa, breastfeeding impairment, and result in cosmetic deformities include infection perichondritis and necrosis of the Nose Infection, jewelry swallowing or aspiration, perichondritis and necrosis of the cartilaginous nasal wall. Infection nasal wall, and septal hematoma formation requires aggressiveStaphylococcus treatment with a In patients with moderate- to high-risk cardiac conditions. antibiotic agents that have good coverage against species that commonly colonize the nasal mucosa. Mupirocin is replace a retracted foreskin) has who has had a medical or health effective and offers excellent been associated with urethral and problem related to body piercing; coverage against Gram-positive cocci. glans88 piercings in uncircumcised they most commonly reported Fluoroquinolones have thePseudomonas advantage men. The foreskin may be reduced infections (74%), bleeding (30%), of excellent skin penetration and manually after a penile nerve block. allergic reactions (26%), and bruising If this maneuver is unsuccessful, and keloids (19% each) (see Table 2). added coverage84 against species. the prepuce can be injected Among those subjects with body with hyaluronidase to allow the piercings, 12% reported having had Nasal jewelry has the potential to 89 edematous fluid to dissipate. personal experiences with health be aspirated or swallowed. Rings problems related to the piercing, placed in the nostril or septum also Penile rings also can cause including infections, bleeding, can migrate forward or be pulled engorgement and priapism (ie, bruising, and allergic reaction. out. As with ear piercing, the studs or persistent erection), requiring Interestingly, those who got their backings of the jewelry may become emergency treatment to preserve piercings in a body-piercing shop embedded and require surgical erectile function. Women with genital 84 were far more likely to report having removal. Abscess formation has piercings can develop bleeding, 85 had an infection (18.4%) than those been reported after nipple piercing. infections, allergic reactions, keloids, 92 90 who got pierced elsewhere (1.9%). and scarring. There are case reports of cellulitis Adolescents were asked to estimate and spread of infection around a It is advisable that sexually active 86,87​ the percent chance of having a breast implant after a piercing. ‍ people with genital piercings piercing-related health problem. However, little information is be counseled that jewelry may The perceived risk for piercing by available about nipple piercing compromise the use of barrier a professional (34%) was lower after breast implantation or chest contraceptive methods. Condoms compared with a nonprofessional wall augmentation. The effects of may be more prone to break, and (73%). Neither those with a piercing nipple piercings on lactation are diaphragms may be more easily nor those who had a problem not clear, but jewelry or scar tissue dislodged during sexual activity with a piercing perceived risk any could impair latching on or block when 1 or both partners have genital ’ differently. Those who had pierced a milk duct and adversely affect an piercings. Avoiding jewelry with themselves perceived much less risk infant s ability to breastfeed. Nipple sharp edges and using looser-fitting from piercing by a nonprofessional piercings should be removed to condoms or double condoms may 91 (50%) than those who had been avoid aspiration by the infant during help avoid some of these problems. pierced but not by themselves. Those lactation. From a unique study on urban with piercings of the face (nose,

Jewelry inserted through the glans teenagers and their knowledge92 of eyebrow, lips, and chin) tended to penis may interrupt urinary flow. piercing complications,​ 33% of all perceive less risk for face piercing Paraphimosis (ie, the inability to subjects reported knowing someone (41.5%) compared with those Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 140, number 4, October 2017 9

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF without (49.7%). In the analysis of generally carved for ear stretching, point of no return, and the hole will “ ” perceived risk, there92 were no effects but other organic materials that not close to a standard piercing size if of race, sex, or age. had the right shape naturally, from the plug is removed. shells to teeth and claws, were also In a recent review from 2012, similar The typical jewelry worn in a used. complications were confirmed, large, stretched piercing is a plug, including systemic infections (such Many cultures have practiced sometimes incorrectly referred to as viral hepatitis and toxic shock stretching, including ancient as a gauge, which refers to the sizing syndrome) and distant infections Egyptians (eg, King Tutankhamen), system used in the United States. It Buddhists from Nepal, Mursi tribal is solid, usually cylindrical, and may (such as endocarditis58 and brain abscesses). It was recommended women of Ethiopia, and the African be flared out at one or both ends that body piercers have their clients Maasai from Kenya and Tanzania. (saddle shaped) or kept in place by complete a medical and social history Stretching is also apparent in the o-rings fastened around the ends. A to identify conditions that may Easter Island heads. Historically, variation on this is the flesh tunnel, predispose them to complications. the practice has been used for the which is shaped in the same way Piercing candidates should choose purpose of tribal status, to scare but is hollow in the middle. Claw-, enemies in war, and for beauty talon-, and spiral-shaped pieces a qualified practitioner58 to perform their piercings. purposes. It has been and still is are also commonplace. Ear weights a common practice for both men in varying degrees of size are also One small study of children and and women. For men, it has been worn, commonly made from silver or adults with congenital heart disease used historically to indicate the bronze, although other metals, such found no cases of endocarditis after standing members of a specific as copper or brass, are occasionally ear piercing, although only 6% of tribe. The bigger the stretching, the used. However, some people are the patients received93 prophylactic higher the ranking the man had. As easily irritated by some metals; antibiotic treatment. for women, ear stretching is more therefore, care should be taken when There have been recent reports of for decorative purposes and also metal jewelry is worn. Ear cuffs (such bacterial endocarditis after nipple signifies when a girl has reached as the gold ones used in South Indian and navel piercings in patients with womanhood. These practices are provinces) or wrapped bead work surgically corrected congenital still important and used today50 by (common among the Maasai of East heart disease. It is important for many tribes and cultures. Africa) are other options, although these are not usually seen in modern physicians to know about planned Stretching, in the context of body 50 piercings so they can consider piercing, is the deliberate expansion Western contexts. antibiotic prophylaxis– in patients of a healed piercing for the purpose With both body piercing and with moderate- or high-risk94 96 of wearing certain types of jewelry. stretching, the system of gauges and cardiac conditions,​ ‍ ‍ although Ear piercings are the most commonly inches is used in gauge size notation, the American Heart Association stretched piercings, with nasal which was originally meant for wire guidelines on endocarditis septum piercings, tongue piercings, thickness determination. A gauge prophylaxis do not specifically and lip piercings and lip plates number denotes a thickness on a mention the need for antibiotic following close behind. Although all standardized scale, which, for most agents in people contemplating97,98​ ear piercings can be stretched to some purposes, starts at 20 gauge (0.03 Sortretching body piercings Methods. degree, cartilage piercings are usually in or 0.81 mm). This is most often more difficult to stretch and more used for the nose and ear post studs. likely to form hypertrophic scars if Importantly, as the gauge number Ear stretching is a modification stretched quickly. Dermal punching decreases to 0 gauge or even 00 is generally the preferred method practiced by and originating from gauge, the50 thickness of the piercing indigenous peoples. Tribes in for accommodating50 larger jewelry in increases. various countries in Africa, Eurasia, cartilage piercings. Regulation of Tattooing and Piercing America, and other indigenous Stretching should be performed in lands have practiced the ritual small increments to minimize the of ear stretching for cultural, potential for damaging the healed Although no reliable estimates exist religious, and traditional purposes. piercing or creating scar tissue. In for the frequency of complications, Ear stretching is a ritual that has North America, most stretching the risk of adverse effects can still been practiced by people all over methods go up by a single, even-sized be reduced by ensuring sanitary the world since ancient times. gauge increment at a time. Stretching tattoo parlors, needles, and inks; Bone, horn, wood, and stone were to 2 gauge, or 6 mm, is considered the comprehensive training of artists; Downloaded from www.aappublications.org/news by guest on September 24, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF TABLE 3 Body Piercing and Tattooing of Minors: Consent and Physical Presence Requirements by State101, ​102 and strong infection-control Type of Outright Prohibition Consent Required Parental Presence Required practices. Individual states have Procedure regulated tattooing for decades to Tattooing Alaska, California, Alabama, Arizona, Arizona, Arkansas, Indiana, address public health concerns. Georgiaa, Iowab, Arkansas, Colorado, Kansas, Louisiana, States did not have any common Idahoc, Illinoisa, Maine, Connecticut, Delaware, Nebraska, North Dakota, Minnesota, Mississippi, Florida, Hawaii, Indiana, Ohio, Pennsylvania, standards until 1999, whenBody Art:the A National Environmental Health New Hampshire, Kansas, Kentucky, Rhode Island, Virginia, Comprehensive Guidebook and Model New York, North Louisiana, Michigan, Wyoming (n = 12) CodeAssociation published Carolina, Oklahoma, Missouri, Montana, 99 Rhode Island, South Nebraska, New Jersey, . This was an interdisciplinary Carolinad, Tennesseee,​f, North Dakota, Ohio, collaboration of academics, public Washington, Wisconsina Pennsylvania, South f health professionals, professional (n = 17) Dakota, Texas , Utah, Vermont, Virginia, West organizations, physicians, Virginia, Wyoming environmental health experts, and (n = 28) body art practitioners. The model Body piercing Idahog, Mississippi, South Alabama, Alaska, Arizona, Arizona, Arkansas, provided detailed recommendations Carolina (n = 3) Arkansas, California, Indiana, Kansas, for and guidelines on sanitation and Colorado, Connecticut, Louisiana, Nebraska, Delaware, Florida, New Hampshire, North infection control. Artist training Georgia, Illinois, Dakota, Ohio, Oklahoma, should include competence in Indiana, Kansas, Pennsylvania, Rhode sterilization procedures, anatomy, Kentucky, Louisiana, Island, Tennessee, Texas, and infection control. As of 2012, Maine, Michigan, Virginia, Wyoming (n 41 states each had at least one Minnesota, Missouri, = 16) Montana, Nebraska, statute in place regulating tattooing. New Hampshire, New The remaining 9 states delegate Jersey, New York, authority to local-level and individual North Carolina, North jurisdictions within those states. Dakota, Ohio, Oklahoma, Even with these regulations, 72% Pennsylvania, Rhode Island, Tennessee, of states do not effectively regulate Texas, Utah, Virginia, sanitation, training and licensing, Wyoming (n = 35) and infection control. Training and a The prohibition does not apply when the tattooing is performed by a physician or licensed technician under a physician’s licensing was the least consistently supervision. regulated topic. Pediatric health care b Prohibition applies only to unmarried minors. c Prohibition for those younger than 14 years, consent required for ages 14 18 years. providers are recommended to learn – d Prohibition for those younger than 18 years, consent required for ages 18–21 years. e about regulations100 in local states or Prohibition for those younger than 16 years, consent required for ages 16–18 years. jurisdictions. f Tattooing is allowed only for covering up an existing tattoo. g Prohibition for those younger than 14 years, consent required for ages 14–18 years. Similarly, there has been considerable debate about adolescents who are minors obtaining tattoos and parental consent requirements (Table 3). At not permitted on a person younger to minors obtaining tattoos and ’ 101 least 45 states have laws prohibiting than 18 years without consent of that piercings in their states. minors from getting tattoos. Thirty- person s parent or legal guardian. Scarification eight states have laws that prohibit The consenting individual needs to Methods both body piercing and tattooing on be physically present at the time of minors without parental permission. piercing, provide evidence of status

Each state varies on legislation101 of as parent or legal guardian, and sign body piercing and tattooing. It a document that provides informed Scarification involves cutting, has been a challenge for states to consent. Penalties for violators are burning, or branding words or keep pace with the new body art fines, prison time, or both; most of images into the skin. Although many forms. Almost every state has laws these laws define violators as the people who have scarification have addressing some aspect of body art. person who performed the tattoo it done by amateurs, professional Nevada has no laws addressing body or piercing. Pediatric health care practitioners of this type of body art; Maryland has limited laws. In providers are encouraged to educate modification use a variety of New Hampshire, body piercing is themselves about laws related methods. The purpose is to create a Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 140, number 4, October 2017 11

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF Advice for Pediatricians

permanent body modification. Some General Issues consultation with an infectious practitioners will also use methods disease specialist is warranted; that enhance scar formation, such as scraping off scabs or irritating 5. Lesions that appear to grow 1. Pediatricians should recognize and/or change within a tattoo are the wound with materials such as the difference between voluntary iodine, citrus juice, or toothpaste. an indication for evaluation for body modifications and the neoplasms; In some traditional cultures, ash impulsive NSSI syndrome; and or clay is packed into the wound 6. Pediatricians should inform to encourage hypertrophied scars. 2. As with all adolescent decisions families of the risk of hemolysis There are many methods in use, that involve significant with red henna temporary including the following: hot and consequences, it is recommended tattoos for children or others cold branding (the latter with liquid that adolescents speak with their with a positive G6PD deficiency. nitrogen), moxibustion (placing parents, guardians, or other Black henna temporary tattoos ’ incense on the skin and allowing responsible adults before having should be avoided because of the it to burn until it s extinguished tattoos placed. significant rate of sensitization; in the skin), cutting with a scalpel, Tattoos and Henna 7. It may be advisable for thermo- and electrocautery, and 103 pediatricians to familiarize laser branding. Complications themselves with local laws and 1. Adolescents and their families regulations related to tattooing to should be informed that tattoos inform families should pediatric are permanent and that removal Scarification does not produce patients be interested in having is difficult, expensive, and only consistent results and does not tattoos placed; and partially effective; always produce the outcomes 8. Adolescents should be counseled desired. Infection is a possible 2. Pediatricians should advise about the implications on job complication of any of these adolescents with a history of placement and maintenance and methods. Scarification artists keloid formation to avoid body education if the tattoos are at all may not be as experienced with modifications that puncture the Piercingsvisible. and Stretching these processes perhaps because3 skin. The outcome is uncertain of less demand for this method. whenever there is trauma to the Additionally, keloids may be a skin resulting in scar; 1. Rinsing with nonprescription complication (essentially, keloid oral cleansers or the topical formation is the complication of 3. Pediatricians should advise application of cleansers is any of these body modification their adolescent patients recommended to prevent infection methods). There are emerging to assess the sanitary and hygienic practices of the tattoo parlors and after oral piercing; treatment strategies for keloid Pseudomonas tattoo artists. This would include scars, but the best strategy is 2. AntibioticStaphylococcus agents with good prevention. People who have had observing the use of coverage against keloids or have family members new, disposable gloves; the and species (eg, with keloids should be informed removal of the new needle and fluoroquinolones) are advised equipment from a sealed, sterile that the outcome104 of scarification is when treating piercing-associated uncertainRegulation. of Scarification container; and the use of fresh, infections of the auricular cartilage; unused ink poured into a new, disposable container with each 3. At clean piercing establishments, new client; the piercer should be observed Although not as regulated as putting on new, disposable gloves tattooing, the amount of state 4. Pediatricians should advise and removing new equipment regulation regarding scarification adolescents to seek medical care from a sterile container; is increasing. As of February 2014, if there are signs and symptoms ’ 4. Adolescents contemplating a 4 states prohibit scarification, and of infection. Normal skin and tongue piercing should be advised 16 other states legislation could soft tissue infections should be of the high incidence of tooth be interpreted as regulating or considered first, but if there are chipping associated with these prohibiting scarification. Eleven any unusual features, prompt piercings; other states have some regulation as evaluation by a dermatologist

part of body art practice. Nineteen 104 is recommended. If there is 5. Pediatricians play an important states do not address scarification. confirmed mycobacterial infection, role in promoting injury Downloaded from www.aappublications.org/news by guest on September 24, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF prevention by recommending About.com Tattoos: tattoo.about.com; Dyer, IN: Peds-R-Us Medical that all jewelry be removed US Food and Drug Administration. Education; 2013 (includes DVD). during contact sports to avoid Think Before You Ink: Are Tattoos LeaAvailabled Authors at: www.​peds-r-​ ​us.​com. endangering the wearer and other Safe? http://​www.​fda.​gov/​ Cora C. Breuner, MD, MPH, FAAP players. Jewelry that interferes ForConsumers/ConsumerUpdates/​ ​ David A. Levine, MD, FAAP with mouth guards or protective ucm048919.htm;​ equipment should be removed Committee on Adolescence, 2016–2017 US National Library of Medicine. before play. Nipple jewelry should Cora C. Breuner, MD, MPH, FAAP, Chairperson be removed before breastfeeding; Piercing and Tattoos: https://​ Elizabeth M. Alderman, MD, FSAHM, FAAP medlineplus.gov/​ piercingandtattoo​ ​ Robert Garofalo, MD, FAAP 6. It is important for pediatricians s.​html; and Laura K. Grubb, MD, FAAP to understand local laws and Makia E. Powers, MD, MPH, FAAP regulations related to piercing to Healthy Children: https://www.​ ​ Krishna K. Upadhya, MD, FAAP inform families should pediatric healthychildren.​org/​English/​ages-​ Stephenie B. Wallace, MD, FAAP Books patients be interested in having a stages/​teen/​Pages/​Tattoos.​aspx. Former Committee Member piercing; and Why Do People Get Tattoos and Other Body Art? David A. Levine, MD, FAAP 7. Adolescents should be counseled Nagle J. about the implications on job New York, NY: Liaisons Tattoo Art Around the World. placement and maintenance and Rosen Publishing; 2011; Laurie L. Hornberger, MD, MPH, FAAP – Section on education if the piercings are at all Adolescent Health Scarificationvisible. Baily D. Liwei L. Hua, MD, PhD – American Academy of New York, NY: Rosen Publishing; Child and Adolescent Psychiatry Erasing the Ink: Getting 2011; and Margo A. Lane, MD, FRCPC, FAAP – Canadian Rid of Your Tattoo. Paediatric Society 1. Teenagers with a personal or Spalding F. Meredith Loveless, MD, FACOG – American College family history of keloids should New York, NY: of Obstetricians and Gynecologists be cautioned about the risk Rosen Publishing; 2011. Seema Menon, MD – North American Society of Body Piercings Pediatric and Adolescent Gynecology associated with scarification Web Sites CDR Lauren B. Zapata, PhD, MSPH – Centers for and other body modification Disease Control and Prevention processes; and Staff 2. Infections resulting from Association of Professional Piercers: scarification may be treated Karen S. Smith www.​safepiercing.org;​ James D. Baumberger, MPP similar to other skin and soft US National Library of Medicine. tissue infections, with standard Piercing and Tattoos: https://​ topical or systemic antibiotic medlineplus.gov/​ piercingandtattoo​ ​ agents. s.​html; and Resources for Information About Abbreviations Tattoos and Body Piercings Healthy Children: https://www.​ ​ healthychildren.​org/​English/​ages-​ Tattoos stages/​teen/​Pages/​Body-​Piercing.​ G6PD: glucose-6-dehydrogenase Web Sites Books aspx. NSSI: nonsuicidal self-injury Body Piercing Removal: NTM: nontuberculous Healthcare Professionals Handbook. mycobacteria Alliance of Professional Tattooists DeBoer S. PPD: paraphenylenediamine Inc: www.​safe-​tattoos.​com;

Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 140, number 4, October 2017 13

Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF References 1. Heywood W, Patrick K, Smith AM, et al. 12. Quaranta A, Napoli C, Fasano F, 22. Pew Research Center. Current decade Who gets tattoos? Demographic and Montagna C, Caggiano G, Montagna MT. rates as worst in 50 years. 2009. behavioral correlates of ever being Body piercing and tattoos: a survey on Available at: www.​people-​press.​org/​ tattooed in a representative sample young adults’ knowledge of the risks 2009/​12/​21/​current-​decade-​rates-​as-​ of men and women. Ann Epidemiol. and practices in body art. BMC Public worst-​in-​50-​years/​. Accessed May 23, 2012;22(1):51–56 Health. 2011;11:774 2017 2. Pew Research Center. Tattoo taboo. 13. Purim KSM, Rosario BA, Rosario CS, 23. Gouveia A. Survey: tattoos hurt your 2010. Available at: www.​pewresearch.​ Guimarães ATB. 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Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF auricular chondritis. Pediatr Emerg due to Mycobacterium abscessus 98. Wilson W, Taubert KA, Gewitz M, Care. 1999;15(3):189–192 after body piercing. Clin Infect Dis. et al; American Heart Association 73. Geor ge J, White M. Infection as 2001;33(1):131–134 Rheumatic Fever, Endocarditis, a consequence of ear piercing. 86. Javaid M, Shibu M. Breast implant and Kawasaki Disease Committee; American Heart Association Council on Practitioner. 1989;233(1465):404–406 infection following nipple piercing. Cardiovascular Disease in the Young; Br J Plast Surg. 1999;52(8):676–677 74. Liu C, Bayer A, Cosgrove SE, et al; American Heart Association Council Infectious Diseases Society of America. 87. de Kleer N, Cohen M, Semple J, Simor on Clinical Cardiology; American Heart Clinical practice guidelines by the A, Antonyshyn O. 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Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF Adolescent and Young Adult Tattooing, Piercing, and Scarification Cora C. Breuner, David A. Levine and THE COMMITTEE ON ADOLESCENCE Pediatrics 2017;140; DOI: 10.1542/peds.2017-1962 originally published online September 18, 2017;

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