Regulation and standardization are needed as the popularity of tattooing and body piercing increases.


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Nurses are continually challenged to improve patient education, advance patient safety, apply scientific principles, and push for health promotion in our evolving, multicultural society. Although tattooing and body piercing may not appeal to everyone, it's becoming mainstream for those between the ages of 18 and 30. Current estimates of prevalence range from 24% for tattoos among 18-to-50-year-olds1 and 30% to 50% for piercings among 18-to-23-year-olds.2 Among women ages 45 to 70, permanent makeup on or around the eyes, lips, and eyebrows, also known as cosmetic tattooing, is also increasing in popularity.


Making body art procedures a safe experience is an important concept for this industry, because state regulations vary considerably.3 Some states set very specific standards for sanitation, sterilization, personnel, and environmental matters; others require artists to be supervised by physicians; and still others require body art studios only to have a business license. The age at which body art can be obtained also varies. For invasive body art procedures, which includes tattooing, piercing, branding, implantation, scarification, tongue splitting, and cosmetic tattooing, artists still have no federal safety standards to follow regarding bloodborne pathogens. These standards should include "sanitation, sterilization, procedures for single-use items, competency requirements for personnel, infection control, client record keeping and retention, preparation and care of the body art, enforcement measures, and prohibitions related to the services."3


The Food and Drug Administration does not approve, standardize, or regulate ingredients for tattoo pigments, nor is there a national database of body art prevalence and complications. Because tattooing and body piercing are invasive procedures, I believe artists should adhere to the most comprehensive model of Oregon and Kansas body art regulations-written examination on the regulations with mandatory continuing education. Because of the popularity of tattooing and body piercing, the National Institute for Occupational Safety and Health expects this summer to launch an educational, industry-specific Web site for body artists about the dangers of bloodborne pathogens.


Making body art safe also may mean helping customers make better decisions about the site for the art rather than encouraging the use of risky piercing sites, such as the uvula (which, if not properly cared for, can lead to respiratory infection, difficult intubation, and jewelry aspiration) or cheek (where complications can include leakage of mucus and jewelry aspiration). Customers should also consider the current debate over whether tattoos in the lumbar area interfere with epidurals.


Training is essential. Unfortunately, in many states, anyone can begin to tattoo or create an artificial opening for jewelry after purchasing the necessary equipment for approximately $300 and hanging a business sign. No knowledge of anatomy, sanitation, sterilization, infection control, or skin preparation and care are required. In Texas, for example, nail technicians, who perform no invasive procedures, must complete at least 600 educational hours, including 320 clinical hours for procedures, but tattoo artists and body piercers face no such requirements.4 Reputable body artists will respect and adhere to safe body art practices and support enforceable regulations that ensure high-quality client care.


Using safe products. The safety and properties of products, such as the pigments used in tattooing, are of concern, not only because there is limited knowledge about the ingredients, which are placed in the skin right below the epidermis, but also because removing them can be problematic: although removal with Q-switched laser treatment continues to improve, green, yellow, white, and some brightly colored pigments are still difficult to remove. In addition, some yellow tattoo pigments have been found to contain carcinogens, and laser treatment of those inks can create other carcinogens.5, 6


The complication rate with piercings ranges from 17% to 45%, and in some body sites the rate is even higher.7, 8 Many ear piercing-related complications result from the customer's poor choice of shop; one study found that having a body piercing performed at a studio is much safer than having one performed at a shopping mall.9 Piercings done at stores located at shopping malls or kiosks often have untrained salespeople who use piercing guns to insert inexpensive brass- or nickel-filled jewelry and market ill-advised aftercare solutions containing benzalkonium chloride. Biocompatible, hypoallergenic jewelry, such as implant-grade stainless steel or titanium or solid white or yellow gold, should be used.


Contamination can occur if the piercer does not wash her or his hands properly; does not wear protective gloves; handles the client's hair, clothes, or the surface of the piercing site; or uses unclean equipment, or if the customer fails to perform proper aftercare. It is therefore important to explain and discuss aftercare instructions verbally and to provide them in writing before the client leaves or have them posted on a Web site so the client follows them conscientiously for as long as the piercing is in place. A piercing should be thought of as a skin fistula kept open by jewelry. The healing of body piercing sites depends on the location, and clients should be aware that infections can occur as long as the piercing site is open. Daily cleansing with soap and water is advised. The actual "toughening" of the skin tissue around the piercing site can take a year or longer to occur.10 This photo essay provides another example of how nurses continue to be advocates of health wherever they work. -Myrna L. Armstrong, EdD, RN, FAAN, professor at Texas Tech University Health Sciences Center School of Nursing at Highland Lakes in Marble Falls.




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3. Armstrong ML. Tattooing, body piercing, and permanent cosmetics: a historical and current view of state regulations, with continuing concerns. J Environ Health 2005;67(8):38-43, 54, 53. [Context Link]


4. Texas Department of Licensing and Regulation. Cosmetology administrative rules. 16 Texas Administrative Code, section 83.106. Health and safety standards-manicure and pedicure services. 2006. http://www.license.state.tx.us/cosmet/cosmetrules.htm#83106. [Context Link]


5. Cui Y, et al. Photodecomposition of Pigment Yellow 74, a pigment used in tattoo inks. Photochem Photobiol 2004;80(2):175-84. [Context Link]


6. Vasold R, et al. Tattoo pigments are cleaved by laser light-the chemical analysis in vitro provide evidence for hazardous compounds. Photochem Photobiol 2004;80(2):185-90. [Context Link]


7. Mayers LB, et al. Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 2002;77(1):29-34. [Context Link]


8. Greif J, et al. Tattooing and body piercing: body art practices among college students. Clin Nurs Res 1999;8(4):368-85. [Context Link]


9. More DR, et al. Ear-piercing techniques as a cause of auricular chondritis. Pediatr Emerg Care 1999;15(3):189-92. [Context Link]


10. Armstrong ML, Kelly L. Tattooing, body piercing, and branding are on the rise: perspectives for school nurses. J Sch Nurs 2001;17(1):12-23. [Context Link]