Tattoos and piercings: a review for the emergency physician.

Tattoos and piercings are increasingly part of everyday life for large sections of the population, and more emergency physicians are seeing these body modifications (BM) adorn their patients. In this review we elucidate the most common forms of these BMs, we describe how they may affect both the physical and psychological health of the patient undergoing treatment, and also try to educate around any potential pitfalls in treating associated complications.

INTRODUCTION

Tattoos and piercings (T&P) are ancient practices of body modification. The word tattoo comes from Polynesia and was first described by Captain Cook in 1769. The art form was named for the tapping noise made by a tattoo needle on the skin, which in the native tongue was tatau or tatu.[1] Piercing, including the ear lobe, is also an ancient process, defined as the insertion of a needle to create a fistula for decorative ornaments. First recorded in the Middle East more than 5 thousand years ago, the practice is mentioned in Genesis 24:22 when Abraham asks his older servant to find a wife for his son Isaac. One of the gifts given to Rebecca, Isaac's new wife, by the servant was a golden earring. Since then, ear piercing has become so well accepted that most scientific literature excludes the ear lobe in the definition of body piercing.

Social acceptability of these practices varies widely from culture to culture. Catholicism and Judaism have banned the practice of tattooing.[2] Esthetics, personal expression, religious views, communication, and style are all motivations for obtaining a tattoo or a piercing. Once relegated to the margins of society (bikers, military, sailors), tattoos and piercings are now common across all ages and both genders in what has been described as an epidemic. For the emergency physician (EP), tattoos and piercings have become important nonverbal clues about the patient's lifestyle and, furthermore, are increasingly the cause of an emergency department visit.[3,4]

This review provides EPs with the tools to be able to assess the lifestyle or social background of their patients, to be able to understand the medical complications that may arise as a result of body modification, and to have a deeper understanding of the psychologic associations of tattooing and, when necessary, the relevance of the body modification to the current chief complaint.

EPIDEMIOLOGY

Within Western society there has been a shift from the stereotype of the tattooed sailors, who used tattoos to communicate their travel and services, the outsider biker of the 1960s (Hell's angels), and the gang members of the 1980s to the ornamental tattoo, which is now part of a collection of body modifications among women as much as men. Recent surveys completed in 2002 and again in 2006 have shown an increase in prevalence in tattoos within the US population.[5,6] In 2002, a Harris poll showed a tattoo prevalence of 16%, whereas in 2006 a North American survey of 18 to 50 year olds found that 24% had tattoos and 14% had body piercings (excluding the ear). The surveys found that those who were tattooed were more likely to be less well educated, to have a high recreational drug use, and were less likely to show any religious affiliation.

Tattooing can be used to camouflage intravenous drug abuse, where it involves the antecubital fossa, and has an important place within generalized medical therapy. Its use is seen as a camouflage for dermatologic disease, can be added as a final stage in many plastic reconstructive procedures, and is also used for guidance in radiation therapy, endoscopic surgery, and ophthalmologic procedures.

Studies, which have looked at the epidemiology of piercings, have found that 2% of Americans report having piercings (not including the ear lobe) and that females get more piercings than men. Among young adults who have piercings there is a high rate of associated eating disorders.[7] Studies also show that persons who get piercings are more likely to partake in risky activities, including drug taking and sexual promiscuity, and have a higher risk of incarceration. The educational status and income of persons with T&P are generally lower, although these educational and economic disparities are lessening as T&P becomes more mainstream (Table 1).[8,9]

Table 1.

Piercing terminology.9

MEDICAL RELEVANCE FOR THE EMERGENCY PRACTITIONER

There are several ways that T&P are relevant to the practicing emergency practitioner (Table 2).

Table 2.

Medical relevance of tattoos and piercings (T&P)

Interpretive Relevance

For the EP, T&P presents a window to the lifestyle and life experience of the patient. Many questions relevant to the history can be answered by a review of the T&P present. Figures 1 through 4 show examples of information obtained from T&P. While interpretation is not as simple as it was 30 years ago, when sailors, military members, and gangs had the most tattoos, relevant information is often within reach of the observant EP.

Figure 1

“LW” is a gang affiliation meant to be seen when wearing sandals.

Complications of Tattoos

Tattoo complication rates show a prevalence of approximately 2% to 3%. Table 3 summarizes the complications associated with tattoos, many of which will be encountered by EPs. Most complications are related to infection that can be traced back to individual tattooist practicing a nonsterile technique. In particular, the jail and intravenous drug-using population is at risk for hepatitis B and C and methicillin-resistant Staphylococcus aureus infection.10–12. Even syphilis has been transmitted by a tattoo artist licking the tattoo needle.[13] Failure to recognize a tattoo as the source of a complication leads to incorrect therapy. In many cases the tattoo is not correctly linked to the medical problem because the patient may have multiple risky behaviors.

Table 3.

Medical complications of tattoos.[15]

Complications of Piercings

Complications of piercings are more common than those of tattoos and studies show rates as high as 9%. The types of complications include local or systemic infections, traumatic insertion, poor cosmesis, and rejection of foreign body, as well as migration and embedding.[14] These are summarized in Table 4.

Table 4.

Medical complications of piercings and pocketing.[23,25]

Jewelry is mainly body-site specific and made from metal. Metals used include stainless steel, gold, titanium, and various alloys. When these alloys contain nickel, there are associated allergic skin reactions and contact dermatitis. Specific complications relevant to the EP are summarized in Table 5. Rarer complications of piercings include bacterial endocarditis, tetanus, piercing migration with embedding, and even a case reported of appendicitis from a swallowed piercing that occluded the appendiceal aperture.[15-18]

Table 5.

Summary of specific piercing and/or pocketing complications by anatomic location.

Psychologic Associations of Body Modifications

The EP should be more concerned about illnesses and suicidal behavior in those with body modifications. Tattooing correlates with the perception of decreased mental health, and tattooing and body piercing together correlate highly with increased “sensation-seeking” behavior.[19] A study of young tattooed Korean males conducted in Korea, where body modification is considered part of counterculture, used the Minnesota Multiphasic Personality Inventory personality test and found high scores in items of psychopathic deviance and schizophrenia, suggesting that those with tattoos were impulsive, hostile, and prone to delinquent behavior.[20] A data analysis of 4,700 individuals who responded to a Web site (www.bmezine.com) for body modification found a high frequency of abuse in the background of those who participated. This survey also found that 36.6% of the males had suicidal ideation and 19.5% had attempted suicide. For the females, a statistically significant higher suicidality rate was found, with percentage values of 40.8% and 33.3% respectively.21 Skegg[22] noted that piercing was more common among women rated as having low constraint or high negative emotionality and was less common among those with high positive emotionality. Therefore, one can conclude that body piercing and tattoos, especially in females, could be a sign of suicidal behavior. However, no association has been found with eating disorders.[7]

Some authors have attempted to show positive association for these body modifications. In a study of women with eating disorders, the authors suggested that body piercing could be seen as reflecting a positive attitude towards the body, an expression of care.[23] In addition people with piercings are more likely to give attention to their physical appearance and are less likely to be overweight than people without piercings.[22]

REMOVAL OF TATTOOS AND PIERCINGS

Burris and Kim[24] found that 50% of persons with tattoos express regret and wish for tattoo removal. The quest for tattoo removal reflects earlier poor decision making and an embarrassing stigma often perceived by the age of 40 years. Tattoos may cause immediate and delayed hazard to health and are not easy to remove. Delayed complications include development of allergic, hypersensitivity, or granulomatous reactions that require tattoo removal.[25] On average, tattoo regret occurs 14 years after tattooing and has spawned a whole new industry. Nonprofit organizations also provide tattoo removal to gang members wishing to remove their tattoos (www.homeboy-industries.org). Tattoos can be removed by mechanical, chemical, or thermal methods.

Alternatives to permanent tattoos include the Indian technique of staining the skin with henna. This will fade over a period of 7 to 10 days. In the past year there has been the development of nonpermanent tattoo ink. This technique uses ink-containing beads that are deployed in the same method as used previously. However, the ink can be fully removed by single-pass laser treatment (www.freedom2ink.com) that dissolves the bead, allowing the dye to be exposed to enzymes, laser, and UV rays.

SUMMARY

Tattoos and piercings have become widespread practices that enjoy greater social acceptance than ever before. Body modification is important to the EP because it provides information about the “patient.” The physician can learn a great deal about these patients via their body modification, including information of immediate relevance to their medical evaluation. Secondarily, T&P are directly responsible for an increasing number of emergency department visits due to both immediate and delayed complications. The EP armed with knowledge about T&P/body modifications can forge more functional doctor-patient relationships, obtain critical historical data, and provide better treatment and referral for this patient population.