A teenager presents with itching and swelling along the area of a recent tattoo on the lower leg. She notes that the area has become swollen and is itching and draining (Figure 81-1). On examination there is swelling over the areas of red dye usage. The pediatrician recognized this as an allergy to the red dye and noted that there were signs of excoriations and some crusting. This was secondary to the scratching that broke the skin and allowed for a secondary infection to begin. The physician treated the secondary infection with oral cephalexin and referred the patient to dermatology for consideration of intralesional steroid treatment of the red dye allergy.

A teenager presents with a tender red lump around an embedded neck piercing (Figure 81-2A). The physician notes that there is a granuloma around the piercing site on the left. The patient requests removal of this piercing which is performed in the office. Four months later a new granuloma forms around the piercing on the right neck (Figure 81-2B). The patient requests removal of the second piercing and acknowledges that it is not a good idea for her to get any additional piercings.

Tattoos and piercings in both the adult and adolescent populations have become more commonplace. The complications of both have increased as the popularity of body art grows.

Tattoos and piercings are also called body art.

Dye, pigment, and ink are all interchangeable when referring to the color used in tattoos.

• Body art including tattooing, piercings and scarification have been practiced worldwide since the beginning of history.

• Tattoos are increasingly popular in the US with an estimated percentage of adults with one or more tattoos at about 21 to 25 percent in 2012.¹

• More adolescent and adults are choosing both tattoos and piercings as an expression of uniqueness.²

Complications result from permanent tattooing or piercing dependent on the location of the body, the healing time and the type of body art chosen. Because both tattoos and piercings break the protective skin barrier, there are increased risks for infections and bleeding. Further complications for piercings include an increased risk for local trauma, tearing of the skin and mucous membranes, keloid formation, and site-specific piercing complications. Delayed wound healing is also a problem with piercings and may complicate the body art.⁴ Healing times for piercings vary by body location and are shown in Table 81-1.

• Risk of complications is more common with piercings than with tattoos and reportedly range from 17 to 69 percent.⁵ Genital piercings are especially prone to infections (Figures 81-3 and 81-4).⁷

• Risks for infection from tattoos is related to contaminated dyes (pigments) and may include bacterial infections such as staph species, mycobacterial,^6–8 viral such as hepatitis B or C, and fungal.⁴

• The most common reported tattoo skin reaction is a hypersensitivity reaction to the pigment. The red pigment is most likely to provoke an allergic reaction (Figures 81-1 and 81-5).

• Risks for piercings can be site specific and among these may be delayed healing, allergic reactions to metal of the piercing, (usually to the nickel component in the jewelry), and keloid formation at the piercing site (common in ears) (Figure 81-6).