Clinical Review
Health Risks Associated with Tattoos and
Body Piercing
Susannah Grimm Poe, EdD, BCBA–D, and Anne Cronin, PhD, OTR/L
ABSTRACT
• Objective: To review the health risks associated with
tattoos and body piercing.
• Methods: Review of the literature.
• Results: Tattooing and piercing have become increas-
ingly popular practices in the United States. There
are important physical and behavioral risks associ-
ated with these forms of body modification. The most
common complications from tattooing include skin
infections and allergic reactions. Minor complications
such as infection and bleeding occur frequently with
piercings, but major complications have also been
reported. Tattoos and piercings appear to be a marker
for risk-taking behavior.
• Conclusion: Clinicians should understand the poten-
tial complications of these procedures and be able to
counsel patients on how to reduce their health risks.
T
attoos and piercings are ancient practices of body
modification that have gained widespread ac-
ceptance in modern society, particularly among
young adults. Tattoos involve the insertion of colored
pigment into the dermal layer of the skin with the goal
of creating a permanent marking. They are commonly
applied using an electrically powered handheld tattoo
machine that moves a needle up and down to inject ink
through the epidermis and deposit a drop of ink into the
dermis [1]. The cells of the dermis are more stable com-
pared with those of the epidermis, so the ink will mostly
stay in place for a person’s lifetime [2].
Body piercing is defined as the insertion of a needle
or specially designed piercing gun to create a fistula-like
opening into either cartilage or skin for the introduc-
tion of decorative ornaments [3]. These ornaments can
include jewelry, plastic or wood plugs, beads, or pearls.
Body piercing has been part of ritualistic or cultural
practices for centuries but is rapidly becoming a world-
wide mainstream fashion trend, especially among young
women aged 17 to 25 years [4]. Ear piercing has become
www.jcomjournal.com Vol. 21, No. 7 July 2014 JCOM 315
so well accepted that most studies of body piercing do
not include earlobe piercing [5].
There are important physical and behavioral risks
associated with body modification. In this paper, we
review the epidemiology, potential complications, and
behavioral factors associated with tattoos and piercings.
Epidemiology
Tattoos are increasingly popular, with a 2012 Harris poll
indicating that 1 in 5 adults has at least 1 tattoo [6], up
from 14% in 2008 [7]. In the 2012 poll, adults aged 30
to 39 are most likely to have a tattoo (38%) compared
to both those younger (30% of those 25–29 and 22%
of those 18–24) and older (27% of those 40–49, 11% of
those 50–64 and just 5% of those 65 and older). Women
are slightly more likely than men, for the first time since
this question was first asked, to have a tattoo (23% versus
19% in men). Current US body piercing rates are approx-
imately 36% [3]. Body piercing is more popular among
women than in men [8]. Among adolescents, body pierc-
ing is performed considerably earlier than tattooing [9].
The head area is the favored location for piercing, while
the most common location for a tattoo is the limb [10].
Associated Health Risks
Tattoos
The most common complications that result from tattoo-
ing are skin infections and allergic reactions to the tattoo
ink. Extensive skin puncturing can result in bleeding
and prolonged leaking of serosanguinous fluid. Pyoder-
mal infections can include temporary inflammation at
the site of needle puncture, superficial infections such
as impetigo and ecthyma, and deeper infections such
as cellulitis, erysipelas, and furunculosis [11]. Unsterile
equipment and needles can transmit infectious diseases
From the West Virginia University School of Medicine,
Morgantown, WV.
 health risks of body art
such as hepatitis [2]. Human immunodeficiency virus
is theoretically transmissible this way, but no cases of
HIV infection caused by tattooing have been docu-
mented [12].
Skin reactions to tattooing include aseptic inflam-
mation and acquired sensitivity to tattoo ink, especially
red ink, but also to chromium in green ink, cadmium in
yellow ink, and cobalt in blue ink [13]. The reaction can
manifest as either allergic contact dermatitis or photo-
allergic dermatitis. Cutaneous conditions that localize in
tattooed areas include vaccinia, verruca vulgaris, herpes
simplex, herpes zoster, psoriasis, lichen planus, keratosis
follicularis (Darier disease), chronic discoid lupus erythe-
matosus, and keratoacanthoma. Other possible but less
common conditions include keloid, sarcoidal granuloma,
erythema multiforme, localized scleroderma, and lymph-
adenopathy [12].
A recent outbreak of nontuburculous nycobacterial
infection was linked to contaminated tattoo inks [14].
Contamination can occur during the manufacturing pro-
cess due to use of contaminated ingredients or when inks
are diluted with nonsterile water by tattoo artists [15].
Investigations of 22 cases of tattoo-associated NTM skin
infections in 4 states that occurred during 2011–2012
found that ink was contaminated with NTM before use
[16]. M. chelonae, one of several disease-causing NTM
species, can cause lung disease, joint infection, eye prob-
lems and other organ infections. These infections can be
difficult to diagnose and can require treatment lasting 6
months or more [15].
Tattoo laws and regulations vary by state. The inks
and ink colorings (pigments) used for tattoos are subject
to regulation by the US Food and Drug Administration
as cosmetics and color additives. However, the FDA has
not traditionally enforced its authority over tattoo inks.
The FDA encourages reporting of tattoo-associated
complications to its MedWatch program (www.fda.gov/
Safety/MedWatch/).
Malignancies reported to develop within tattoos
include squamous cell carcinoma, basal cell carcinoma,
malignant melanoma, leiomyosarcoma, and dermato-
fibrosarcoma protuberans [17,18]. These malignancies
may be coincidental, but carcinogenicity of the tattoo is
as yet unknown. Another concern is that a malignancy
within a tattoo is more difficult to identify on skin ex-
amination [11,17].
Rarely, tattoos or permanent makeup might cause
swelling or burning in the affected areas during magnetic
316 JCOM July 2014 Vol. 21, No. 7 www.jcomjournal.com
resonance imaging (MRI) exams. The metallic ferric acid
pigments used in tattoos can conduct heat on the skin
during MRI, resulting in traumatic burns [19]. This has
also been reported to occur with tattoos with nonferrous
pigments. In some cases, tattoo pigments can interfere
with the quality of the image, such as when a person with
permanent eyeliner has an MRI of the eye [19].
Patients may self-administer tattoos using sewing
needles, forks, paper clips, or pens, and colorants may
include charcoal, soot, mascara, or ink. The use of unpro-
fessional tattooists and piercers, who often have limited
knowledge of health and hygiene precautions, is more
likely to lead to complications [10].
Piercings
While most body piercings are not problematic, the
potential for localized infections as well as associated
systemic disease is present as long as the piercing site
remains open [20]. Bacterial skin infections at or near
the site are the most commonly reported complication
of body piercings, with causative organisms primarily
consisting of Staphylococcus, group A beta-hemolytic
Streptococcus, and Pseudomonas [21]. Contributing to
the health risks of piercing is the reluctance of patients
to seek qualified medical intervention when initial site
irritation, pain, or oozing occurs [21].
Systemic infections have been reported. More than 25
infective endocarditis cases in the past decade have come
from tongue, navel, earlobe, lower lip, and nipple piercings
[21]. Infective endocarditis should be considered in indi-
viduals with a new piercing (ie, up to 4 months), with or
without a history of congenital heart disease, who present
with unexplained fever, night chills, weakness, myalgia,
arthralgia, lethargy, or malaise [22]. General complica-
tions include allergic contact dermatitis (eg, from nickel
or latex), bleeding, scarring and keloid formation, nerve
damage, and interference with medical procedures such as
intubation and blood/organ donation [20].
Oral piercings may lead to difficulty speaking and
eating, excessive salivation, and dental problems. Oral
and nasal piercings may be aspirated or become em-
bedded, requiring surgical removal. Tongue piercing,
usually performed without anesthesia, may cause dam-
age to teeth and gums, including dental fractures [23]
and changes in chewing and speech. Because of the
tongue’s vascular nature, prolonged bleeding can result
if vessels are punctured during the piercing procedure.
In addition, the technique for inserting tongue jewelry
 Clinical Review

Table 1. Potential Complications of Body Piercings

Piercing Site Potential Complications

Ear Allergic reaction, auricular perichondritis, embedded earrings, infection, keloid formation, perichondral
abscess, traumatic tear
Genitals (women) Allergic reaction, compromise of barrier contraceptives, infection, keloid formation
Genitals (men) Frictional irritation, infection, paraphimosis, penile engorgement, priapism, recurrent condyloma, urethral
rupture, urethral stricture, urinary flow interruption
Mouth Airway compromise, altered eating habits, gingival trauma, hematoma formation, increased salivary flow,
infection, injury to salivary glands, interference with radiographs, loss of taste, Ludwig’s angina, pain,
permanent numbness, speech impediments, tooth fracture or chipping, uncontrolled drooling
Navel *
Bacterial endocarditis, frictional irritation, infection, jewelry migration and rejection
Nipples *
Abscess formation, bacterial endocarditis, breastfeeding impairment, infection
Nose Infection, jewelry swallowing or aspiration, perichondritis and necrosis of nasal wall, septal hematoma
formation

Reprinted from reference 38.

*In patients with moderate- to high-risk cardiac conditions.

may abrade or fracture anterior dentition, and digital
manipulation of the jewelry can significantly increase the
potential for infection [24]. In fact, complications arising
from oral piercing are so numerous—and in some cases
life-threatening—that the American Dental Asso-
ciation has issued a formal statement opposing the
practice [24].
Other site-specific complications have been reported
(Table 1). Piercing tracts in the ear, nipple, and navel
are prone to tearing [20]. Galactorrhea may be caused
by stimulation from a nipple piercing. Genital pierc-
ings may lead to infertility secondary to infection, and
obstruction of the urethra secondary to scar formation.
In men, priapism and fistula formation may occur. Navel
piercings account for 40% of complications arising from
body piercing and are commonly associated with infec-
tion and scarring. The peri-umbilical area is a popular
site for self-piercing and a modern fashion statement,
but friction from clothing in this area may account for
higher infection rates, longer healing time and increased
scarring [25].
Behavioral Risk
While the presence of tattoos or piercings is not neces-
sarily indicative of any aberrant patterns of behavior,
clinicians should consider not only medical but also
behavioral risks when tattoo or piercing is evident in
patients, especially if that body modification is extreme.
Koch et al [26] report stark differences in the levels of de-
viant behavior among college students with just 1 tattoo
versus those with 4 or more (Table 2), and among those
with just 1 to 3 piercing versus those with 7 or more.
Respondents with intimate piercings reported deviance
levels similar to the heavily tattooed [26].
Several studies have found that those with body modi-
fications engaged in earlier or more frequent sexual activ-
ity and had a greater number of sexual partners [26–28].
A study by Deschesnes and colleagues [29] reported that
certain “externalized” risk behaviors were more com-
monly associated with tattooed and pierced youth than
with their unmodified counterparts, including the use
of drugs, gang affiliation, school truancy, and problem
gambling. Other studies of high school youth have found
that tattooing was significantly and independently associ-
ated with other high-risk behaviors, including sexual in-
tercourse, binge drinking, smoking, marijuana use, gang
membership, truancy, and school failure [30]. However,
a survey of college students found that, compared to in-
dividuals with no body art, individuals with 1 tattoo and
less than 4 piercings had no greater likelihood to engage
in high-risk behaviors [31].
Conversely, some researchers have attempted to show
a positive association for body modification. In a study
of women with eating disorders, the authors sug-
gested that body piercing could be seen as reflecting
a positive attitude towards the body, an expression of
self-care [32]. In addition, people with piercings are
more likely to give attention to their physical appearance
and are less likely to be overweight than people without
piercings [33].

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 health risks of body art

Table 2. Tattoos and Deviance: Comparative Percentages and Chi-Square Analysis

Variable No Tattoos 1 Tattoo 2–3 Tattoos 4+ Tattoos P Value

Cheat on college work
Once/year or less 81.6 (n = 1217) 82.0 (n = 123) 83.1 (n = 59) 76.5 (n = 13)
Once/semester or more 18.4 (n = 275) 18.0 (n = 27) 16.9 (n = 12) 23.5 (n = 4) NS
Sex partners in past year
2 or less 79.9 (n = 620) 69.4 (n = 86) 64.6 (n = 42) 64.3 (n = 9)
3 or more 20.1 (n = 156) 30.6 (n = 38) 35.4 (n = 23) 35.7 (n = 5) p < 0.01

8 or less 91.2 (n = 705) 80.8 (n = 101) 69.2 (n = 45) 57.1 (n = 8)

9 or more 8.8 (n = 68) 19.2 (n = 24) 30.8 (n = 20) 42.9 (n = 6) p < 0.001
Binge drinking in last week
No 63.9 (n = 925) 52.4 (n = 76) 55.1 (n = 38) 71.4 (n = 10)
Yes 36.1 (n = 522) 47.6 (n = 69) 44.9 (n = 31) 28.6 (n = 4) p < 0.01
Monthly marijuana use
Never 87.3 (n = 1308) 70.7 (n = 106) 66.2 (n = 47) 75.0 (n = 12)
Once or more 12.7 (n = 190) 29.3 (n = 44) 33.8 (n = 24) 25.0 (n = 4) p < 0.001
Other illegal drug use
Never 95.6 (n = 1428) 90.7 (n = 136) 91.5 (n = 65) 93.3 (n = 14)
Once or more 4.4 (n = 65) 9.3 (n = 14) 8.5 (n = 6) 6.7 (n = 1) p < 0.05
Arrest other than traffic
Never 91.5 (n = 1373) 81.3 (n = 122) 87.3 (n = 62) 29.4 (n = 5)
Once or more 8.5 (n = 127) 18.7 (n = 28) 12.7 (n = 9) 70.6 (n = 12) p < 0.001

Reprinted from reference 26.

Stirn and Hinz [34] concluded that most people
who partake in body modification clearly do not do it
because they have any psychological problems. However,
for a few, modifications may be utilized as a convenient
means to either realize psychopathological inclinations,
such as self-injury, or to overcome psychological traumas.
The prevalence of self-injury is unknown, though it is
believed to be a growing problem. While self-injury is
believed to be a low-lethality behavior, teens who hurt
themselves are at increased risk for suicide related to their
underlying anxiety or depression. Moreover, self-harmers
report that they often had their skin tattooed or body
pierced to help overcome a negative experience, or simply
to experience physical pain. Another clue that self-harm
and piercing/tattooing might in some cases be linked
derives from the fact that many of the self-harmers said
they had ceased cutting themselves after obtaining their
first piercing or tattoo [35]. The increasing incidence
makes deliberate self-harm a problem that all health
care providers dealing with adolescents are likely to
encounter.
Given the link between body modification and “ex-
ternalized risk behaviors” in young people, tattooing and
body piercing may serve as clinical markers for health
care professionals, potentially identifying those who
may be involved in activities that hinder their health and
development [29]. For example, closer examination of
teens who wear long sleeves or clothing inappropriate for
weather could reveal cuts, burns, carvings, or bruises that
are self-inflicted.
Patients are more likely to discuss the issue of body
art if the clinician does not speak or act judgmentally
[1]. Practitioners who are concerned that their tattooed
patient might be self-injuring or engaging in other risky
behaviors should invite a discussion with the patient,
perhaps using general terms, such as “Sometimes people
may get involved in self-injury and don’t know where to
turn for help. I will try to help you if you are ever worried
about that.” As always, if the clinician suspects a patient
is engaged in self-harming activities, an immediate refer-
ral should be made for mental health evaluation and any
necessary intervention.

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Preventatively, clinicians should provide targeted and
repeated education to transmit the message of effective
decision-making and evaluation of risks to children in
the early elementary grades, since some students start to
obtain body art as early as fifth grade.
Regret and Removal
Over time, many individuals regret getting tattoos and
wish to have them removed [35]. In some cases, delayed
complications, like the development of allergic, hyper-
sensitivity, or granulomatous reactions, require tattoo
removal. On average, tattoo regret occurs 14 years after
tattooing and by the age of 40 years.
Removal is more painful and laborious than the tat-
tooing itself, and complete removal, with no scarring, is
often not possible. The American Society for Dermato-
logic Surgery reports that in 2011, its doctors performed
nearly 100,000 tattoo removal procedures, up from the
86,000 performed in 2010 [36]. Pulsed lasers have been
used to remove tattoos for more than 20 years. With
this procedure, pulses of high-intensity laser energy pass
through the epidermis and are selectively absorbed by the
tattoo pigment. The laser breaks the pigment into smaller
particles, which may be metabolized or excreted by the
body, or transported to and stored in lymph nodes or
other tissues [37].
Other removal techniques include dermabrasion and
surgical excision. Do-it-yourself tattoo removal oint-
ments and creams can be purchased online, but they have
not been approved by the FDA and there is no clinical
evidence that they work. Furthermore, tattoo removal
ointments and creams may cause unexpected reactions,
such as rashes, burning, scarring, or changes in skin pig-
mentation [37].
Clinician’s Role
Body art provides a window into an individual’s unique-
ness, and acknowledging body modifications can help
build trust and develop the physician/patient relation-
ship. The health professional armed with knowledge
about body modifications can forge more function-
al relationships, obtain critical historical informa-
tion, and provide better treatment and referral for this
population [5].
Having a clinician who is a trusted, nonjudgmental
source of information and intervention for patients who
choose body art will reduce the health risk of com-
plications associated with tattooing and piercing [1].
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Clinical Review
Unfortunately, only 14% of the population identify health
care professionals as a common resource for information
on body modification. Instead, young adults endorsed
friends (82%), body piercing shops (61%), and tattoo
shops (51%) as their top information sources. Clinicians
should help patients make informed decisions about body
art and counsel them about the importance of universal
precautions [35].
Corresponding author: Susannah Grimm Poe, EdD, 176
Gilboa Rd., Fairmont, WV 26554, spoe@hsc.wvu.edu.
Financial disclosures: None.
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