COMMENT
Piercing Complications
Overall, the ear, tongue, and oral cavity were found to be the sites with the most associated complications recorded in the literature, and local infection and tissue damage were found to be the most prevalent types of complications. A plethora of treatments were used to manage piercing-induced complications, including surgical or medical treatments and avoidance (Supplemental Information). Reports by Metts6 and Escudero-Castaño et al7 provide detailed protocols and photographs of piercings.
Infections
Our review found that local infections were commonly reported complications associated with body piercings, which is consistent with other studies.1 The initial trauma inherent in the piercing process followed by the presence of an ongoing foreign body lends itself to an increased risk for developing these complications. Wound healing after piercing also varies based on the piercing location.
The rate and severity of the infection are influenced by the anatomic location of the piercing, hygiene, method of piercing, types of materials used, and aftercare.8 Piercing cartilage sites, such as the helix, concha, or nose, increases susceptibility to infections and permanent deformities. Cartilage is particularly at risk because of its avascular nature.9 Other studies have reported similar incidences of superficial localized infections; infectious complications were seen in 10% to 30% of body piercings in one study,3 while 45% of American and Australian college students reported infection at a piercing site in a second study.10
Systemic Issues
Systemic issues are potentially the most dangerous piercing-induced complications, though they were rarer in our analysis. Some serious complications included septic emboli, fatal staphylococcal toxic shock syndrome, and death. Although some systemic issues, such as staphylococcal toxic shock syndrome and septic sacroiliitis, required extensive hospital stays and complex treatment, others had lifelong repercussions, such as hepatitis and HIV. One report showed an increased incidence of endocarditis associated with body piercing, including staphylococcal endocarditis following nasal piercings, Neisseria endocarditis following tongue piercings, and Staphylococcus epidermidis endocarditis following nipple piercings.11 Moreover, Mariano et al12—who noted a case of endocarditis and meningitis associated with a nape piercing in a young female in 2015—reinforced the notion that information pertaining to the risks associated with body piercing must be better disseminated, given the potential for morbid or fatal outcomes. Finally, nonsterile piercing techniques and poor hygiene were found to contribute substantially to the increased risk for infection, so it is of utmost importance to reinforce proper practices in piercing salons.4
Immune-Mediated Issues
Because piercings are foreign bodies, they are susceptible to both acute and chronic immune responses. Our study found that allergies and dermatitis made up almost half of the immune-mediated piercing complications. It is especially important to emphasize that costume jewelry exposes our skin to a variety of contact allergens, most prominently nickel, heightening the risk for developing allergic contact dermatitis.13 Moreover, a study conducted by Brandão et al14 found that patients with pierced ears were significantly more likely to react to nickel than those without pierced ears (P=.031). Although other studies have found that allergy to metals ranges from 8.3% to 20% in the general population,15 we were not able to quantify the incidence in our study due to a lack of reporting of common benign complications, such as contact dermatitis.
Tissue Damage and Local Problems
Our review found that tissue and oral damage also were commonly reported piercing complications, with the most common pathologies being trauma, dysesthesia, bleeding/bruising, and dental damage. Laumann and Derick16 reported that bleeding, tissue trauma, and local problems were common physical health problems associated with body piercing. Severe complications, such as abscesses, toxic shock syndrome, and endocarditis, also have been reported in association with intraoral piercings.17 Moreover, other studies have shown that oral piercings are associated with several adverse oral and systemic conditions. A meta-analysis of individuals with oral piercings found a similar prevalence of dental fracture, gingival recession, and tooth wear (34%), as well as unspecified dental damage (27%) and tooth chipping (22%). Additionally, this meta-analysis reported a 3-fold increased risk for dental fracture and 7-fold increased risk for gingival recession with oral piercings.18 Another meta-analysis of oral piercing complications found a similar prevalence of dental fracture (34%), tooth wear (34%), gingival recession (33%), unspecified dental damage (27%), and tooth chipping (22%).19 Considering the extensive amount of cumulative damage, wearers of oral jewelry require periodic periodontal evaluations to monitor for dental damage and gingival recession.20 There are limited data on treatments for complications of oral piercings, and further research in this area is warranted.
Proliferations and Scars
Although proliferations and scarring were among the least common complications reported in the literature, they are some of the most cosmetically disfiguring for patients. Keloids, the most common type of growth associated with piercings, do not naturally regress and thus require some form of intervention. Given the multimodal approach used to treat keloids, as described by the evidence-based algorithm by Ogawa,21 it is not surprising that keloids also represented the complication most treated with medical therapies, such as steroids, and also with direct-target therapy, such as liquid nitrogen therapy (Supplemental Information).
