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Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023
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Tongue splitting and tattooing. Image from Wikimedia Commons | William Cho (CC BY-SA 2.0).
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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]
Image from Wikimedia Commons | HeadOvMetal. [CC BY-SA 2.0)]
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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]
Image from Wikimedia Commons | James Heilman, MD. [CC BY-SA 4.0)]
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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.
Image from Wikimedia Commons | Rodrigo Galindez [Creative Commons Attribution 2.0 Generic (CC BY 2.0).]
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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.
Images from Wikimedia Commons (adapted) | Gaudencio Garcinuño (left; background) | Elisa Coria (right). (CC BY-SA 2.0 and CC BY 3.0, respectively).
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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.
Image from Wikimedia Commons | Lish Daelnar [Creative Commons Attribution 3.0 United States (CC BY 3.0 US).]
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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]
Image from Wikimedia Commons (adapted) | Bethanie Hall (public domain).
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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]
Image from Wikimedia Commons (adapted) | Zara J (CC BY-SA).
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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]
Adapted images from Kirkham CL, Monks SM, Crawford SB. Int J Emerg Med. 2019;12:22. PMID: 31455219; PMCID: PMC6712609 (left) and Parriault MC, Chaponnay A, Cropet C, et al. PLoS One. 2019;14(6):e0218992 (right) (both CC BY 4.0).
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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
Image from Wikimedia Commons | Cory Doctorow (CC BY-SA 2.0).
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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]
Image from Asif M, Quiroga L, Sabo A, Caffrey J. Clin Case Rep. 2019;7(1):104-106. PMID: 30656019; PMCID: PMC6333081. (CC BY 4.0).
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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
Image from Wikimedia Commons | Ricardo Almeida (CC BY 2.0).
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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]
Image from Ruiz-Villaverde R, Sánchez-Cano D. Pan Afr Med J. 2013 Oct 11;16:49. PMID: 24648862. (Open Access).
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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.
Direct brow lift procedure iages courtesy of Medscape.
Body Modifications: Dermatologic Reactions and Risks
Michael Payette, MD, MBA, FAAD; Kristen Russomanno, MD | October 3, 2023 | Contributor Information
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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Contributor Information
Authors
Michael Payette, MD, MBA, FAAD
Founding Partner
Central Connecticut Dermatology
CCD Research
Cromwell, CT
Disclosure: Michael Payette, MD, MBA, FAAD, has disclosed the following financial relationships:
Served as an advisor and/or consultant for: FIDE, AbbVie, Amgen, Eli Lily, Janssen, Novartis, ONVIV Atopic Dermatitis Expert Panel, Sanofi-Genzyme/Regeneron, UCB.
Kristen Russomanno, MD
MedStar Georgetown University Hospital/Washington Hospital Center
Departments of Internal Medicine and Dermatology
Washington, DC
Disclosure: Kristen Russomanno, MD, has disclosed no relevant financial relationships.
Reviewer
Brett Sloan, MD, FAAD
Professor of Dermatology
University of Connecticut School of Medicine
Farmington, CT;
Residency Site Director
Connecticut Veterans Affairs Healthcare System;
Assistant Clinical Professor
Yale University School of Medicine
New Haven, CT;
Editor-in-Chief, Journal of the American Academy of Dermatology Case Reports
Disclosure: Brett Sloan, MD, FAAD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Journal of the American Academy of Dermatology Case Reports.
Donohoe M. Beauty and body modification. Medscape Ob/Gyn: Women's Health in Context. April 19, 2006; Accessed: September 14, 2023. Available at: http://www.medscape.com/viewarticle/529442.
Kaatz M, Elsner P, Bauer A. Body-modifying concepts and dermatologic problems: tattooing and piercing. Clin Dermatol. 2008 Jan-Feb;26(1):35-44. PMID: 18280903
Desai N. Body piercing in adolescents and young adults. UpToDate.com. December 1, 2021; Accessed: September 7, 2022. Available at: https://tinyurl.com/AdolescentBodyMod.
Mari W, Alsabri SG, Tabal N, et al. Novel insights on understanding of keloid scar: article review. J Am Coll Clin Wound Spec. 2016 Nov 30;7(1-3):1-7. PMID: 28053861
Herskovitz M, Goldsher D, Finkelstein R, Bar-Lavi Y, Constantiescu M, Telman G. Multiple brain abscesses associated with tongue piercing. Arch Neurol. 2009:66(10):1292. PMID: 19822789
Escudero-Castano N, Perea-Garcia M, Campo-Trapero J, Cano-Sanchez, Bascones-Martinez A. Oral and perioral piercing complications. Open Dent J. 2008;2:133-6. PMID: 19444317
Hudson KL, Sayer A. Body piercing guide—sites, styles, what to expect, healing, and care. Byrdie. March 2, 2022; Accessed: September 14, 2023. Available at: https://www.byrdie.com/body-piercings-guide-4078450.
Wright J. Earlobe stretching. Pitts-Taylor V, ed. Cultural Encyclopedia of the Body. Westport, CT: Greenwood Publishing Group; 2008:100-2.
Wright J. Scarification. Pitts-Taylor V, ed. Cultural Encyclopedia of the Body. Westport, CT: Greenwood Publishing Group; 2008:466-73.
Perez-Cotapos ML, de Cuyper C, Cossio L. Tattooing and scarring: technique and complications. de Cuyper C, Perez-Cotapos ML, eds. Dermatologic Complications with Body Art: Tattoos, Piercings and Permanent Make-Up. Berlin: Springer-Verlag; 2010: Chap 3.
Raza S, Mahmood K, Hakeem A, et al. Adverse clinical sequelae after skin branding: a case series. J Med Case Rep. 2009 Jan 23;3:25. PMID: 19166615
Lodder M. Tongue splitting. Pitts-Taylor V, ed. Cultural Encyclopedia of the Body. Westport, CT: Greenwood Publishing Group; 2008:515-6.
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