
Body Modifications: Dermatologic Reactions and Risks
The ancient practice of body modification—including body piercing, skin implants, earlobe stretching, scarification, tongue splitting, branding, and tattooing—has had a wide range of aesthetic, cultural, sexual, and religious purposes. Such modifications remain common in various countries and cultures in the modern era.[1,2] Western cultures began to rapidly adopt these arts in the late 20th century and to use them as a form of personal self-expression.[2-4]
However, body modifications pose a risk of complications that are often overlooked or understated. Although these complications are mostly avoidable with better patient education and proper antiseptic technique, unlicensed surgery or procedures performed outside of a medical environment can have life-threatening consequences.[5,6]
Body Modifications: Dermatologic Reactions and Risks
Body Piercing
Body piercing, defined by the American Academy of Dermatology (AAD) as "creation of an opening in the body of a human for the purpose of inserting jewelry or other decoration,"[3] is one of the most mainstream forms of body modification. In the United States, it is commonly seen in the ears, eyebrow, nose, navel, tongue, lips, nipples, and external genitalia.[2] However, even more unusual locations, such as the uvula (shown), may be pierced. Body piercing is increasingly common among adolescents and young adults. A survey of Millennials (age 18-29) in the US found that 23% overall—and 35% of women—had a piercing in a site other than an earlobe.[5]
Complications of skin piercing
The most common adverse reaction is localized infection, most often of the umbilicus or ear. Piercing can be painful initially, and pain may persist. Other common reactions include contact dermatitis (see slide 3), edema, hematoma formation, localized argyria (skin discoloration), and keloid formation (see slide 4).[4] Serious, and possibly life-threatening, complications include sepsis and transmission of HIV infection or hepatitis, with the additional risk of tetanus and staphylococcal or streptococcal toxic shock syndrome.[4,6]
Body Modifications: Dermatologic Reactions and Risks
Allergic reactions to jewelry
The image above illustrates allergic contact dermatitis occurring in response to an earring. In addition, a bacterial superinfection has developed at the site; this is a common, complication, because allergic reactions interfere with the normal architecture of the skin and thereby increase vulnerability to infection.
Most allergic reactions to jewelry involve nickel.[7] In inexpensive jewelry, nickel is typically used as a base metal, which may then be plated with other metals. Jewelry made from 18- or 24-carat gold, sterling silver, or pure platinum is less likely to cause allergic reactions.[7]
Body Modifications: Dermatologic Reactions and Risks
Unintentional scarring/keloid formation
Keloids represent an excessive tissue response to skin injury. They often form at the site of lacerations, burns, skin trauma, and surgical wounds and thus can develop at the site of piercings as well. Keloids extend beyond the borders of the original wound, may be symptomatic (ie, pruritus), and usually do not regress spontaneously. Medical and surgical therapies are of limited efficacy;[9] keloids typically recur after excision.[8]
The image above shows an extremely large keloid on the earlobe.
Body Modifications: Dermatologic Reactions and Risks
Complications of Oral Piercings
Because the tongue is highly vascularized and innervated and is close to many oral structures (eg, teeth and airway), oral piercings can give rise to myriad complications. Local infections may develop, as well as infections of vital organs (eg, endocarditis, brain abscess) and sepsis.[10,11] Tongue piercing (shown) can cause major hemorrhage if care is not taken to avoid important blood vessels. If a nerve in the tongue is damaged, paresthesia may result, as well as difficulty in swallowing, speaking, and chewing. If an allergic reaction occurs, anaphylaxis may develop, with the potential for tongue swelling and airway obstruction.[11]
Other complications that may arise from oral piercing include gingival recession, difficulty maintaining oral hygiene (leading to periodontitis), cracking of the teeth, hypersalivation, and aspiration of jewelry.
Body Modifications: Dermatologic Reactions and Risks
Corset Piercing
Corset piercing is a style of multiple piercings in bilateral, often parallel, rows that are threaded with a string or ribbon to appear as though a corset is being laced up the body.[12] Although the back is often the site for these piercings, the neck and extremities are also common locations.
Body Modifications: Dermatologic Reactions and Risks
Earlobe Stretching
Earlobe stretching, or ear gauging (shown), involves piercing the earlobes, allowing the piercing to heal, and then gradually stretching the hole with various types of gauges, plugs, or rings.[13,14] Stainless steel is typically used for the rings and plugs in the stretching process; once healing is complete, decorative plastic and wooden pegs may be used.[14]
Complications of earlobe stretching
The main complication of earlobe stretching is deformity that often must be surgically corrected if the person subsequently desires normal-appearing earlobes.[15] If the earlobes are stretched more than 0.5 in (1.25 cm), they are unlikely to heal on their own.[16]
Body Modifications: Dermatologic Reactions and Risks
Skin Implants
Skin implants involve the surgical placement of a foreign object subdermally (shown) or transdermally. This procedure can be done at nearly any anatomic location. Transdermal implants—also known as microdermal implants, single-point piercings, dermal implants, or surface anchors[17,18]—protrude through the skin,[17] whereas subdermal implants are completely seated under the skin to achieve a three-dimensional (3D) effect on the skin surface.[19]
Body Modifications: Dermatologic Reactions and Risks
Transdermal implants
Transdermal implants (shown) are typically made of stainless steel or titanium, with titanium usually preferred because of its lower rejection rate.[18] They consist of two components: (1) an anchor or base piece implanted beneath the skin, with a step that protrudes from the surrounding skin surface; and (2) a jewelry piece screwed into the threaded hole in the step of the anchor.[17,18]
Subdermal implants
Subdermal implants for aesthetic/decorative purposes are typically made from silicone and placed underneath the skin through an incision.[19,20] The incision is sutured closed, and the skin then heals over the implant, creating a three-dimensional raised effect/design. To accommodate large implants, the space below the incision may have to be gradually expanded.[20]
Body Modifications: Dermatologic Reactions and Risks
Shown are three subdermal penile implants with no evidence of disease (left) and paraphimosis (right) in another patient resulting from subdermal penile implants inserted in an incarcerated individual in a prison environment.
Complications of skin implants
The incidence of complications is generally low with transdermal implants, though healing tends to take a relatively long time (eg, 8-12 weeks).[18]
Complications of subdermal implants include the following[20]:
- Implant rejection
- Infection
- Tissue destruction and skin ulceration
- Nerve and muscle damage
- Allergic reactions
- Chronic pain
Body Modifications: Dermatologic Reactions and Risks
Scarification
Scarification (cicatrization, shown) is the intentional creation of a scar for purposes of decoration or, in some cultures, ritual (eg, tribe identification, rites of passage, or marking of milestones in life); the end result is a rise or indentation in the skin that resembles a carving.[21] It may be accomplished via skin cutting, removal, or abrasion[21] with a sharp instrument (eg, scalpel, glass, or wood); other modalities include electrocautery/laser, chemicals, freezing, and heated metal.[22] Foreign bodies (eg, ash or soot) and colored pigments may be mixed into the wounds to make the scars more visible.[21,22]
Branding
Branding is a specific type of scarification achieved by burning a pattern onto the skin.[21]. Most often, the process involves heat (eg, from a hot iron or heated metal), but another method is cold ("freeze") branding, in which an iron or metal is dipped in liquid nitrogen and then applied to skin.[23]
Body Modifications: Dermatologic Reactions and Risks
Shown are blistering, erythema, and edema of the right forearm two weeks post a solar branding procedure in which sunlight is deliberately focused on the skin.
Complications of scarification/branding
There are case reports of septic shock, cavernous sinus thrombosis, and splenic abscesses in people who have undergone branding.[23] All of them had chronic medical comorbidities that made them more vulnerable to severe complications, and two of them died of their complications. Other, more common complications include transmission of infection (eg, hepatitis and HIV), as well as edema, allergic reactions, unintended scarring, keloids, hair loss, squamous cell carcinoma, and disfigurement.[23]
Body Modifications: Dermatologic Reactions and Risks
Tongue Splitting
Tongue splitting (shown), also known as forking the tongue, involves midline bisection of the tongue and is usually performed surgically (eg, with a surgical scalpel or laser or through cauterization).[21] The exposed tissue is then sutured closed to prevent the tongue from healing back into one entity.[24-25]
Complications of tongue splitting
When tongue splitting is not performed in a controlled medical setting, the risks for complications are much higher than if the procedure were performed by a trained surgeon. Possible complications include the following[24,26]:
- Excessive blood loss and hemorrhage
- Infection, including hepatitis, HIV, and sepsis
- Damage to nerves and glands in the tongue, which may lead to altered taste, loss of sensation, and speech impairment
- Tongue swelling that could obstruct the airway
Body Modifications: Dermatologic Reactions and Risks
Tattooing
In tattooing, ink is injected into the skin to create a permanent image. There are also temporary tattoos, such as those made using henna, but the complications discussed here relate to permanent tattooing. In a professional tattoo studio, the skin is cleaned with alcohol and iodine, and then ink is applied into the desired design with sterile needles. The tattoo pigment is taken up by macrophages in the skin, where it becomes permanent.[27]
Body Modifications: Dermatologic Reactions and Risks
Complications of Tattooing
The above image shows the abdomen of a 23-year-old patient who presented with pearled papules over a tattoo. The patient was diagnosed with molluscum contagiosum, which may have been transmitted by improperly sterilized instruments or contaminated ink.
The health risks associated with tattooing are greatly increased when the procedure does not occur under regulated conditions. Localized skin infections appear to be the most frequent complications. Localized hypersensitivity reactions to tattoo ink, as well as scarring and keloid formation, are also common.[28] If adequate antisepsis and disinfection protocols are not practiced, the risk for infection, especially with community-associated methicillin-resistant Staphylococcus aureus (MRSA), is greater. Sepsis and/or systemic infection with hepatitis and HIV are rare sequelae, but may occur in unsanitary conditions.
Body Modifications: Dermatologic Reactions and Risks
Other Body Modifications
A variety of other body modification exists. For example, the American Society of Plastic Surgeons lists the following on its website:
- Breast surgery (augmentation, reduction, lift, fat transfer breast augmentation)
- Fat reduction (liposuction, nonsurgical fat reduction, laser/ultrasound-assisted liposuction)
- Body lifts (arm, body, thigh, body contouring, buttock augmentation, tummy tuck)
- Face and neck surgery (brow lift [shown]), ear surgery, facelift, neck lift, chin surgery, eyelid surgery, facial implants, rhinoplasty)
- Minimally invasive procedures (botulinum toxin, dermabrasion, microdermabrasion, dermal fillers, laser skin resurfacing, permanent makeup, chemical peels, laser hair removal, skin rejuvenation and resurfacing, sclerotherapy)
- Male- and female-specific plastic surgeries
The wide range of complications inherent to many of these procedures is beyond the scope of this presentation. As these and other types of body modification are likely to increase in popularity, simple awareness of the modifications available will aid medical professionals in everyday interactions with patients. For patient education on modifications performed outside of the medical environment, the Association of Professional Piercers provides several informational brochures regarding body piercings, including the selection of a piercer and piercing aftercare (https://www.safepiercing.org).
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