Infections Associated with Body Modification
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Journal of the Formosan Medical Association (2012) 111, 667e681 Available online at www.sciencedirect.com journal homepage: www.jfma-online.com REVIEW ARTICLE Infections associated with body modification Samson Sai-Yin Wong a, Sally Cheuk-Ying Wong b, Kwok-Yung Yuen a,* a Department of Microbiology, Research Centre for Infection and Immunology, Faculty of Medicine, The University of Hong Kong, Hong Kong b Department of Microbiology, Queen Mary Hospital, Hong Kong Received 30 August 2012; received in revised form 10 October 2012; accepted 25 October 2012 KEYWORDS Although exact statistics are lacking, body modifications for cosmetic purposes are performed body modification; in many countries. The commonest forms include tattooing, body piercing, and breast and body piercing; facial augmentation using implants or injectable fillers. Liposuction and, to a lesser extent, breast implants; mesotherapy are also practiced in many countries. Infective complications of these procedures mesotherapy; include local infections, transmission of bloodborne pathogens (viral hepatitis and human tattooing immunodeficiency virus), and distant infections such as infective endocarditis. Presence of foreign bodies, long healing time of piercing wounds, and poor compliance with infection control practices of some practitioners all predispose the recipients to infections. Apart from the endogenous microbial flora of the skin and mucosae, atypical mycobacteria, especially the rapid growers, have emerged as some of the most important pathogens in such settings. Outbreaks of infection are commonly reported. We hereby review the current knowledge of the topic with specific focus on infections associated with tattooing, body piercing, breast augmentation, mesotherapy, liposuction, and tissue filler injections. Greater awareness among consumers and health-care professionals, as well as more stringent regulations by the health authorities, is essential to minimize the health risks arising from these procedures. Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. Introduction subdermal and transdermal implantation, and breast augmentation, to more drastic procedures such as tongue Body modification or body art for nontherapeutic purposes splitting, genital modification, and gender reassignment encompasses a vast variety of procedures, ranging from surgery. There are few formal statistics on the prevalence common procedures such as tattooing, body piercing, of body modification in most parts of the world. In a study of undergraduates in the United States, the prevalence of body piercing and tattooing was found to be 51% and 23%, respectively.1 In Europe, the prevalence of tattooing has * Corresponding author. Department of Microbiology, Research e Centre for Infection and Immunology, Faculty of Medicine, The been reported to be 6 12% in different studies, and that of 2,3 University of Hong Kong, Hong Kong. body piercing about 20% in some studies. Similarly, the E-mail address: [email protected] (K.-Y. Yuen). incidence or risk of infective complications following these 0929-6646/$ - see front matter Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. http://dx.doi.org/10.1016/j.jfma.2012.10.016 668 S.S.-Y. Wong et al. procedures is unknown. This is due to the fact that there is metallo-beta-lactamase-producing Enterobacteriaceae had no information on the denominator of persons who have received prior medical care in the Indian subcontinent.45 received these procedures, and that cases reported in the literature tend to be isolated case reports or well- Tattooing documented outbreaks. The vast majority of individuals who went for tattooing or body piercing had not considered In the process of tattooing, colored inks are introduced the potential health risks prior to the procedures.4 In most mechanically into the skin dermis by electrically driven countries, practitioners of body modification and body art needles. Local and systemic health problems are common parlors are not strictly regulated by law, and therefore after tattooing, which persist even for weeks after the stringent adherence to the recommended infection control procedure.2 Infective complications may result from the practice is sometimes doubtful. Persons embracing body cross-contamination of inadequately sterilized equipment modifications sometimes also engage in other risky behav- and contaminated tattoo inks. Reported infections, which iors such as illicit drug use and alcoholism, which may e were sometimes associated with outbreaks in the tattoo predispose them to other infective complications.5 7 recipients, include tuberculosis (lupus vulgaris), leprosy, Body modification procedures can be complicated by verruca vulgaris and verruca plana due to human papillo- local pain, inflammation, infection. Circumstances predis- maviruses, zygomycosis, community-associated methicillin- posing individuals to infections after body modification are resistant Staphylococcus aureus, and atypical mycobac- manifold. Various microbial and environmental factors e e teria, especially the rapid growers.10 13,46 53 Noninfective contribute to the transmission of microbial pathogens causes of local skin reactions to tattoos, including allergic, during body modification procedures. Since these proce- granulomatous, and lichenoid reactions or coincidental dures inevitably involve breaches in the skin or mucosae, lesions such as malignancies, should also be considered as pathogens can be introduced from the normal flora colo- differential diagnoses.54 nizing the surfaces or from exogenous microbes such as Exposure to bloodborne pathogens poses a major infec- contaminated instruments, jewelry, and disinfectants. tious risk to persons receiving tattoos. Although syphilis These infecting organisms can sometimes cause infections used to be a common infection transmitted during tattoo- in distant organs. Organisms such as Pseudomonas aerugi- ing, it is relatively uncommon nowadays. One of the largest nosa and atypical mycobacteria are ubiquitous in the outbreaks of HBV infection affected 34 persons of whom 31 environment. Their resistance to and ability to contaminate were tattooed by one artist and three were secondary low-level disinfectants and antiseptics have been well cases.55 Epidemiological studies have shown tattooing to be documented.8 Other major concerns are bloodborne a risk factor for HCV infection, and a dose-related response infections such as viral hepatitis and human immunodefi- was noted.56,57 In contrast to HCV infection acquired from ciency virus (HIV) infection. High-level viremia can be blood product transfusion, that acquired from tattooing is encountered in patients with hepatitis B virus (HBV) and HIV often subclinical, probably reflecting the smaller inoculum infections, and even minute contaminations with their of viruses transferred in such settings.58 Tattooing has been blood and body fluids can result in infections if disinfection shown to be a risk factor for HIV infection in some studies, of the environment and instruments is inadequate. The but not in others, possibly due to the confounding effects of prolonged survival of hepatitis C virus (HCV) in the envi- e various at-risk behaviors in this group of individuals.59 61 ronment may also contribute to its transmission under such However, a recent case of HIV infection in an Australian circumstances.9 tourist after receiving tattoos in Bali again raised the In many countries, body modification procedures per- possibility of HIV transmission in such settings.62 formed in parlors are not subjected to strict hygienic regulations. The majority of these “minor” procedures are performed in commercial premises or by unlicensed Body piercing personnel, sometimes without strict adherence to infection control guidelines. Sterilization and disinfection of instru- Body piercing involves puncturing of the skin or mucosae ments between clients, choice and maintenance of chem- with subsequent insertion of foreign bodies, such as rings, ical disinfectants and antiseptics, and adoption of bars, or other jewelries. In some procedures, the cartilage a particular infection control practice (such as mainte- is also pierced, as in case of “high piercing” of the ear nance of a sterile field, prevention of cross-contamination, involving the cartilage of the pinna. Common sites of and disposal of biohazardous wastes) often depend on the piercing include ears, eyebrows, lips, navel, nipples, geni- conscientiousness of the premise owners and operators. A talia, nose, tongue, and other parts of the oral mucosa. As number of outbreaks related to such procedures have been in the case of tattooing, body piercing can be associated reported in recent years (Table 1).2,10e44 As a form of with transmission of bloodborne pathogens.63e65 Local “medical tourism”, consumers are often receiving body inoculation of pathogens has likewise resulted in the modifications in overseas countries where the costs are transmission of tuberculosis (lupus vulgaris) and lower. Some of these medical tourism destinations and tetanus.66,67 Bacterial infections of the skin and soft tissues institutions may have less stringent levels of infection tend to be commoner in body piercing than in tattooing control, which might have explained the occurrence of because of the greater degree of tissue damage, presence infection outbreaks among some of the recipients.44 A more of deeper wounds, and placement of foreign bodies recent concern over medical