Continuing Education Activity

Body piercings have become increasingly popular and are a socially acceptable form of body modification. Common sites of piercings are the ears, mouth, nose, eyebrows, nipples, navel, and genitals. Localized cellulitis is the most common infectious complication resulting from body piercings. This activity reviews the evaluation and treatment of body piercing infections and explains the role of the interprofessional team in managing patients with this condition.

Objectives:

• Review the role of the organisms Staphylococcus, Streptococcus, Pseudomonas, Neisseria, and Chlamydia in the etiology of body piercing infections.
• Identify the risk factors for developing body piercing infections.
• Summarize the use of conservative treatment including warm compresses and topical antibiotics in the management of body piercing infections.
• Describe the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients affected by body piercing infections.

Introduction

Body piercings have become increasingly popular and a socially acceptable form of body modification. The most common site of piercings is the ear, with increasing popularity involving the mouth, nose, eyebrows, nipples, navel, and genitals.[1] Localized cellulitis is the most common infectious complication resulting from body piercings. If not identified and treated accordingly these localized infections, though rare, can lead to more serious systemic complications such as Ludwig angina, endocarditis, toxic shock syndrome, and Fournier gangrene as detailed in case reports.[2]

Etiology

The most commonly identified organisms from body piercing infections include skin flora responsible for skin and soft tissue infections such as staphylococcus and streptococcus species though there are a few exceptions. There is a higher rate of incidence of pseudomonas infections when involving the cartilaginous ear and nasal structures.[3] Individuals with genital piercings are at increased risk for sexually transmitted infections such as Neisseria gonorrhea and Chlamydia trachomatis. Additionally, patients colonized with Staphylococcus aureus are at increased risk of infection regarding nasal piercing infections. Also, infection rates are low involving piercings of the lips and tongue despite a large number of bacteria present in the oral cavity.[4]

Epidemiology

A national survey found that of the respondents, approximately 35%, reported having some form of body piercings with 14% endorsing piercings at sites other than the soft earlobe. Women, in general, are more likely than men to have body piercings. Women additionally have more piercings to sites other than the soft earlobe when compared with males.[5] Individuals between the ages of 24 to 34 have the highest prevalence of body piercings. Of those individuals with piercings at sites other than the soft earlobe, 23% reported experiencing a medical complication. One-third of those with body piercings report having received piercings outside of a specified body art studio which raises the concern for increased infection transmission.[6][7]

Pathophysiology

Concerns over non-sterilized and improper cleaning techniques of piercing equipment, as well as, an individual patient's overall hygiene habits and poor piercing aftercare attribute to the increased risk of infection with associated body piercings.[3] There is a higher incidence of infection when involving the ear due to its poor blood supply leading to issues of wound healing. An additional concern arises with genital piercings that can compromise the integrity of barrier contraception and increase the risk for sexually transmitted infections.[3]

History and Physical

Most skin and soft tissue complications will present similarly to localized cellulitis infections or abscesses such as areas of erythema, swelling, warmth, tenderness, fluctuance, and possibly purulent drainage. More systemic symptoms such as fever, tachycardia, malaise, or changes in mentation can vary depending on the location and if a disseminated infection is present.[8][9] It is essential to ask about who performed the piercing, when did the piercing occur, and the equipment used to perform the procedure when evaluating a possible infectious complication from a body piercing.[1]

Evaluation

The diagnosis of minor localized infections is often based on the clinical presentation and does not require the need for extensive testing. Though indications for laboratory testing and imaging may not be present for every patient, some patients may need further evaluation when systemic symptoms like fever, tachycardia, hypotension, or altered mentation are present.[9] Common laboratory testing and imaging may include complete blood count, electrolytes, renal function, lactic acid, plain film x-ray, or ultrasound.[8]

Treatment / Management

Conservative treatment of minor local infections includes warm compress and over-the-counter or prescription topical antibiotics such as bacitracin or mupirocin. Oral antibiotics such as cephalexin or clindamycin provide coverage for streptococcus and staphylococcus. If concerns for methicillin-resistant Staphylococcus aureus exist, then oral trimethoprim/sulfamethoxazole confers adequate coverage. Infected piercings of the high ear involving the cartilaginous structures are likely to be caused by Pseudomonas and are treatable with a fluoroquinolone like ciprofloxacin.

Removal of the piercing jewelry is requisite, and the placement of a loose loop suture through the piercing can be used to maintain the piercing patency throughout the duration of infection treatment. Oral piercings tend to have a lower infection rate but when present are treatable with amoxicillin/clavulanate. The recommended duration of treatment for local cellulitis is five days, but therapy duration extension is possible if there is no sign of symptomatic improvement.[9] The addition of oral alcohol rinses or topical cleaners containing carbamide peroxide can aid in infection healing. Treatment for genital piercing infections should include the consideration to cover for Neisseria gonorrhea and Chlamydia trachomatis with intramuscular ceftriaxone and oral azithromycin in the appropriate setting aside from the standard soft tissue infections. If the patient has not gotten a tetanus vaccination or booster within the last five years, then this should be updated if presenting with an infection after a recent body piercing.

Differential Diagnosis

The differential diagnosis should be relatively straightforward with the complaint centered on the piercing site. Other possible diagnoses could include but are not limited to a retained foreign body, allergic reaction, deep vein thrombosis, sepsis from a disseminated local infection or representation of a bleeding disorder following the initial piercing.[2]

Prognosis

Complications arising from body piercing infections are rare, and antibiotic treatment along with incision and drainage of an abscess is the cornerstone of therapy.[2]

Complications

Potential complications of piercing infections are relatively minor when identified early and treated with appropriate antimicrobials. A delay in the presentation can lead to increased severity of local skin and soft tissue infections such as abscess formation, nasal septal perforation, airway compromise with as in cases of Ludwig angina, or possible dissemination to distant sites such as endocarditis.[4] Lastly, complications of antimicrobial use have the known risk of Clostridium difficile colitis.[2]

Deterrence and Patient Education

Patients need to be counseled on the risks of associated infection when undergoing body piercings. Importance should be placed on infection prevention and the need for utilization of a trusted and certified piercing parlor as these locations have requirements for proper hygiene and sterilization techniques.[2]

Pearls and Other Issues

Rare reports exist of other infections including but are not limited to hepatitis B virus, hepatitis C virus, human immunodeficiency virus, and tetanus.[10] Complications of local infections can have grave implications with reports of toxic shock syndrome due to Staphylococcus aureus and associated ear piercing, endocarditis from nasal a nasal piercing, Ludwig angina from an oral piercing, and abscess formation compromising a breast implant after a nipple piercing, all have documented case reports.[4] For these reasons, it is necessary to identify and treat the localized infections to prevent severe and life-threatening complications.[3]

Enhancing Healthcare Team Outcomes

Culture and gram stain of purulent drainage of skin infections can help aid in the treatment of skin and soft tissue infections, but this is not a requirement (level 2). Alternatively, it is not recommended to perform a swab, biopsy, or blood culture from a cellulitis infection (level 2). For abscesses, incision and drainage is the recommended treatment (level 1). For infections involved with penetrating trauma, as could be the case with a recent body piercing, treatment with antimicrobials directed against methicillin-resistant Staphylococcus aureus and Streptococcus species are recommended (level 2). Recommended treatment duration is five days, but therapy extension is advisable if not improved during that treatment period (level 1).[9]