Dermatologic Complications with Body Art
Christa De Cuyper, Maria Luisa Pérez-Cotapos S Editors
Dermatologic Complications with Body Art Tattoos, Piercings and Permanent Make-Up
Dr. Maria Luisa Pérez-Cotapos S Pontificia Universidad Católica de Chile, Department of Dermatology, Clinica Las Condes, Lo Fontecilla 441, Santiago, Chile
[email protected] Dr. Christa De Cuyper Department of Dermatology AZ Sint-Jan Ruddershove 10 8000 Brugge Belgium
[email protected] ISBN: 978-3-642-03291-2
e-ISBN: 978-3-642-03292-9
DOI: 10.1007/978-3-642-03292-9 Springer Heidelberg Dordrecht London New York Library of Congress Control Number: 2009933268 © Springer-Verlag Berlin Heidelberg 2010 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: Frido Steinen-Broo, eStudio Calamar, Figueres/Berlin Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)
Contents
1
History and Epidemiology of Tattoos and Piercings. Legislation in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anne E. Laumann
1
2
Materials Used in Body Art . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Christa De Cuyper and Davy D’hollander
13
3
Tattooing and Scarring: Technique and Complications. . . . . . . . . . . . Maria Luisa Pérez-Cotapos S, Christa De Cuyper, and Laura Cossio
29
4
Piercings: Techniques and Complications . . . . . . . . . . . . . . . . . . . . . . . Christa De Cuyper, Maria Luisa Pérez-Cotapos S and Laura Cossio
43
5
Cosmetic and Medical Applications of Tattooing . . . . . . . . . . . . . . . . . Christa De Cuyper
53
6
Allergic Reaction to Pigments and Metals. . . . . . . . . . . . . . . . . . . . . . . Werner Aberer, Johan E. Snauwaert, and Ulf-Maria Render
61
7
Techniques and Devices Used for Tattoo Removal . . . . . . . . . . . . . . . . Evelien Verhaeghe
91
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
107
v
Introduction
Body art in its different forms dates back to ancient times. Body modification is a common human characteristic that has been practised on all continents and in all races. Specific types of body art have been associated with specific social, ethnic and religious societies. Temporary decorations include the traditional customs, costumes, the use of jewellery and body painting. Permanent modifications such as piercing and tattooing are old forms of body adornment that have gained popularity as a fashion statement in the last decades and that have been accepted in all social classes nowadays. Cosmetic tattoos or permanent make up have been introduced as an excellent alternative for conventional make up. The technique of micropigmentation consists of implantation of pigment into the skin or the mucosa using a small tattoo pen. The same procedure with a modified instrument, known as dermatography, has found its place in the medical world to camouflage pathological skin conditions such as vitiligo and alopecia or to mask scars and birth marks and it can offer the finishing touch in reconstructive surgery. It can also be used for implantation of pharmacological substances for therapeutic indications. Tattoos are also used as a permanent mark for medical procedures. The imagination in body adornment and body transforming techniques is amazing and endless. More invasive body modifying techniques such as implanting, scarification, branding, scalping and even amputation recently seem to attract the young population and unfortunately often result in impressive, irreversible body mutilation. All body-modifying methods can lead to complications, which depend on the hygienic conditions in which the procedures are performed, on the training and the skills of the practitioner and on the materials used. Allergic reactions can be attributed to the substances used. Poor hygienic standards and careless procedures can result in localised infections but can also lead to severe life-threatening conditions or even result in irreversible damage. Blood-borne diseases can be transmitted (hepatitis B, C, HIV), granuloma and keloid formation can occur. Health care professionals should be aware of the complications that can arise from these procedures. The body art industry is one of the fastest growing industries in the last years unaffected by the economic crisis. Considering the high number of people who have chosen for a tattoo, a piercing or any other form of body modification, one can estimate that millions of people on the globe live with a self-inflicted health risk that could have an important impact and consequences for the health care system in general. Many efforts have been done yet to identify risk factors and to develop preventive measures aimed at protecting public health. Regulation of the composition of the products, harmonisation of the methods for the analytical determination of possible harmful substances, guidelines and recommendations to ensure that procedures are vii
viii
Introduction
carried out under appropriate hygienic conditions can offer a big step forward to promoting consumer health. However there is still a lack of uniform universal regulation and control. The purpose of this book is to illustrate the different aspects of body art starting from the history through epidemiology, to improve the knowledge about materials, with their toxic and allergenic potential, to discuss the procedures and the complications that can arise. Therapeutic modalities will be addressed with a focus on laser techniques for tattoo removal. To realise this book we had the assistance and contributions of many people we would like to thank, in particular our colleagues, our secretaries and our families for their help and support. Brugge, Belgium Santiago, Chile
Dr. Christa De Cuyper Dr. Maria Luisa Pérez-Cotapos S
Contributors
Werner Aberer Department of Dermatology and Environmental Dermatology, Medical University of Graz, Auenbruggerplatz 8, 8010 Graz, Austria Laura Cossio Department of Dermatology, Pontificia Universidad Católica de Chile, Santiago, Chile Christa De Cuyper Department of Dermatology, AZ Sint-Jan, Ruddershove 10, 8000 Brugge, Belgium Davy D’hollander Professor Claraplein 14/002, 2018 Antwerpen, Belgium Anne E. Laumann Feinberg School of Medicine, Northwestern University 676, North St. Clair #1600, Chicago, IL 60611, USA Maria Luisa Pérez-Cotapos S Pontificia Universidad Católica de Chile, Department of Dermatology, Clinica Las Condes, Lo Fontecilla 441, Santiago, Chile Ulf-Maria Render Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, 8010 Graz, Austria Johan E. Snauwaert Augustijnslei 36, 2930 Brasschaat, Belgium Evelien Verhaeghe Department of Dermatology, UZ Gent, De Pintelaan 185, 9000 Gent, Belgium
1
History and Epidemiology of Tattoos and Piercings. Legislation in the United States Anne E. Laumann
Core Messages
› › › › › › ›
Tattooing and body piercing date back to early civilizations. In the past, they were used during initiation rites or as an indication of social status. Tattooing has been used to identify criminals, prisoners, and slaves, and for punishment. Body modification has become more common and more sophisticated over the last 30 years. Body art may be associated with risky behavior. Body piercing may be associated with depression. Regulation in the United States of America is variable from state to state.
1.1 History 1.1.1 Tattoos Tattooing, defined as the practice of producing an indelible mark or figure on the human body by inserting pigment under the skin using needles or other sharp instruments, has probably been around since the beginning of humanity [1]. There is not so much a continuous
A. E. Laumann Feinberg School of Medicine, Northwestern University, 676, North St. Clair #1600, Chicago, IL, 60611, USA e-mail:
[email protected] history related to tattooing, but rather many concurrent happenings in different societies across the world. Tattoos disappear when their canvas goes; in other words, with the death of the individual, so our current information may be more discontinuous than the reality. The famous 5,300-year-old preserved corpse, nicknamed Otzi, found in the mountains of the South Tyrol in 1991 was covered in tattoos. These included linear marks over many of his joints and a cross on the inside of the left knee. They may have been placed to help with pain from his evident arthritis [2, 3]. Dark blackish-blue inscriptions have been found on Egyptian mummies dating as far back as 2100 b.c. Interestingly, it appears that this practice of tattooing was limited to women. It may have been only for decoration, but other hypotheses suggest a ritualistic significance or a relationship to fertility and sexuality. The tattoos were groups of dots and dashes in geometric patterns, often across the abdomen. The oldest of these mummies is that of Amunet, a priestess of Hathor, the Egyptian goddess of love. Later (circa 1532–1070 b.c.), female mummies from the New Kingdom of Nubia (South Egypt) were embellished with representational tattoos, for example, the image of the god Bes, on the thighs. In the late eighth century b.c., Isaiah prophesied “This one will say, ‘I am the Lord’s,’ another will call himself by the name of Jacob, and another will write on his hand, ‘ The Lord’s,’ and surname himself by the name of Israel” [4]. Old testament sayings like this together with the injunction “You shall not make any cuttings in your flesh for the dead nor print any marks upon you: I am the Lord” [5] in Leviticus, composed circa 550–400 b.c., belie the presence of these marks on the bodies of Israelites at that time. This latter admonition may have been motivated by the use of tattoos among non-Jewish people, for example, those of the cult of Baal [6].
C. de Cuyper, M. L. Pérez-Cotapos S. (eds.), Dermatologic Complications with Body Art, DOI: 10.1007/978-3-642-03292-9_1, © Springer-Verlag Berlin Heidelberg 2010
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About the same period, the Pazyryk were a nomadic tribe living in the Altai Mountains of Siberia. A number of their tombs have been opened and previously undisturbed bodies found to be elaborately decorated with real and mythical beasts. These pictures are thought to reflect the societal status of the bearer [6]. Likewise, it is clear that tattooing occurred in China. Although, in some parts men tattooed their hands as a sign of valor and women tattooed the nape of the neck as a sign of marital status, in general, tattooing happened among “barbarian” peoples. Tattoos may have been used as facial cosmetics, to ward off evils spirits, or as marks of slavery or punishment [7]. In Japan, there is evidence from clay figures from the Jomon period (10,000–300 b.c.) of facial tattoos, and later, during the Yahoi period (300 b.c.–300 a.d.) tattooing occurred on the face for decorative and religious purposes and to ward off evil spirits. Later, tattooing fell into disrepute, and during the Kofun period (300–600 a.d.), it was used as a punishment and to
identify “untouchables”. Decorative tattooing, heavily influenced by the imagery of wood-block print artists, developed during the Edo period (1600–1800 a.d.). The Yakuza, who initially were flamboyant and crazy samurai in the service of the emperor, degenerated into the criminal class, and it was this group who became known for elaborate full body tattoos. (Fig. 1.1) These tattoos, even today, may be applied by hand and take many days to complete. Their painful acquisition is a measure of courage and group solidarity. During the Meji era (1868 to present), tattooing has been forbidden, increasing the association with criminality, although, as in the rest of the developed world, tattooing is becoming more mainstream [8]. Little is known about tattooing during the latter part of the first millennium and the early part of the second millennium a.d., but the Inuit (Eskimos), who lived along the Arctic coasts of Siberia, Alaska, Greenland, and Canada, continued to use facial tattoos over the centuries. They served to protect them from enemies,
Fig. 1.1 Nakamura Fukusuke in the role of Koito with Ichimura Ichizo in role of Sashichi. Color woodcut diptych with gauffrage 1858, 7th month. From the play Fuka unbaka ikiji shinwara.
Signed: Toyokuni ga in a Toshidama cartouche. Artist: Utagawa Kunisada (1786–1865). Publisher: Otaya Takishi
History and Epidemiology of Tattoos and Piercings. Legislation in the United States
showed the women could bear pain and were ready for marriage. Traditionally, older women did the tattooing using an unusual method of bone needles blackened with soot, which were threaded through the skin so that the black particles remained embedded in the tracks [8]. Symbols were formed mainly using lines, dots, and geometric designs. Western interest in tattooing reappeared during the second half of the eighteenth century. Captain Cook, a British explorer, and his crew were fascinated by the tattooing they saw on the South Sea Island of Tahiti, the Moko they encountered among the aborigines of New Zealand (Fig. 1.2), and the skin pictures on the inhabitants of Hawaii. The word “tattoo” came from the Tahitian word “tatau,” meaning “the results of tapping,” and it signified the noise made by the mallet when it hit needles made from sharp-toothed bones driven into the flesh. Tattoos among the Marquesan people were used to distinguish rank and age among
Fig. 1.2 Facial Moko. Photographer: Walter Brooks (with permission)
3
men. Tattooing started in the teen years and for men continued throughout their lives to cover the whole body, while women’s tattoos were typically only on the face, lips, ears, feet, and hands. Tattooed individuals, including the famous Omai who was displayed as a human oddity, were brought back on ships to Europe, causing considerable sensation. In turn, the seamen learned the Polynesian tattooing techniques and produced their own designs. A French man, Jean Baptiste Capri, was tattooed on the Marquesas after he had deserted a whaling expedition, and in 1804 he displayed himself in Russia as the first European tattooed attraction, thereby paving the way for many other sideshow human oddities. Traditional tattooing died related to the arrival of protestant missionaries, despite the stories of the English missionary, John Williams, using the local skill to have the word “murderer” tattooed across the upper lip of a woman who had murdered her husband. By 1846, there was sufficient demand among soldiers and sailors and from others who wanted to make livings as “tattooed masterpieces,” for Martin Hildebrandt to open a tattoo shop in New York City. This was followed in 1891 by the development of an electric tattoo machine by “Professor” Samuel O’Reilly and in 1904 by an updated machine with electromagnetic coils set transversely to the tube assembly. Both were based on Thomas Edison’s recently patented electric pens. The design was updated again in 1929 by Percy Waters, a Detroit tattooist, and, with minor modifications, this is the machine that is in general use today. Although still painful, the rapidity of the multiple needle pricks needed to make an elegant tattoo has made the process more bearable, and allowed for the popular spread of the technique. Between the two World Wars, tattoos became so mainstream among working class and military men that Norman Rockwell’s illustration of The Tattooist was on the cover of the middle class magazine, the Saturday Evening Post [9]. Soon after this, a tattoo on the back of the left hand was used in highly successful advertisements disseminated across the United States to sell cigarettes. Even in the modern era, tattooing has not only been used for decorative and voluntary group affiliation purposes, but also for identification purposes, for example for the cataloging of sick Russian and Jewish prisoners in the Auschwitz concentration camp during the Second World War. This was done by using a stamp of numbers made out of needles and rubbing ink into the wounds. Immediately after this during the Korean conflict, it was used to place a permanent marking on the body of an
4
Fig. 1.3 A tear drop at the corner of the eye signifies having committed a murder
individual’s blood type, using a purpose-built electric tattoo machine [10]. In the early 1980s, before it was known what caused this new life-threatening disease, there were discussions about tattooing the genital areas of those with acquired immune deficiency syndrome. This never happened, as far as the author knows. The association with criminals and other marginal groups in the West results not from the forceful placement of tattoos, but relates to the use of these for signaling affiliation with such groups. Tattoos may be done in prison, not by the guards, but by the inmates devising make-shift tattoo implements and using ash or other ink for pigment. These tattoos may have meaning, such as a tear drop close to the eye signaling having committed a murder (Fig. 1.3), or they may symbolize membership in a particular gang, for instance, a Pachuco cross or a five point star. This latter type of tattoo is often performed as an initiation rite on the street or in a public place at the time the wearer joins the gang. In the 1950–1980s, many tattoos were associated with motor cycle groups, as well as punks and hippies [11, 12]. More recently, with the advent of fine arts skill among tattooists, the use of many different types of pigment, and the publicity of celebrities, the practice of decorative tattooing has proliferated among those under 30 years of age across first world countries.
A. E. Laumann
studs, or pins. Like tattooing, body piercing has been practiced in almost every society, but has usually been confined to the ears, mouth, and nose, possibly for religious purposes [13]. Less has been written about this practice than about tattooing, although antique statues and remnants, for instance, from the Mayan civilizations in central America, temple carvings in India, and stone figures in Cambodia [14], as well as remaining jewelry items attest to its happening. It may have been used during initiation ceremonies, for status recognition and for sexual purposes, but, mainly piercing and stretching of the earlobes and the lower lip, and puncturing the nasal septae were done for the practical purpose of keeping jewelry in place. Ear piercing of children and penile piercing are specifically mentioned in the fourth century a.d. Hindu text, the Kama Sutra [15]. The traditional practice of piercing of the cheeks during the Hindu festival, Thaipoosam, is still performed as an act of penance or the fulfillment of a vow [16]. Another traditional Hindu practice, karnavedha, is the piercing of the ears of 3 to 5-year old children. It is usually done by a local goldsmith for beauty, and in some castes, the father will not see his child until after this is done. In parts of Africa, the stretching of the lower lip of women continues to be done for the insertion of large wooden plates, and similarly, earlobes were and still are stretched for beautification (Fig. 1.4). The tribesmen of Papua, New Guinea, continue the tradition of wearing bird’s bone or feathers through their nostrils when they dress for religious, ceremonial, or festive occasions [17]. More recently, it is clear from jewelry pieces and journal articles that only very limited ear piercing was practiced in the West during the first half of the twentieth century [18, 19]. Stories about the Roman senators having nipple piercings and Prince Albert, Queen Victoria’s husband, having a penile ring are probably fictitious, purely designed to market body piercings during the last two decades of the twentieth century [20]. In fact, the modern fashion of body piercing really did not start until the late 1980s [21], although ear piercing was starting to become popular outside the punks and hippies in the United States during the late 1960s.
1.2 Epidemiology 1.1.2 Body Piercing Body piercing is defined as the cosmetic piercing of body parts for the implantation of objects such as rings,
One only has to look around to see that having either a tattoo or a body piercing is quite common place. Despite the many traditions, stories, and injunctions,
History and Epidemiology of Tattoos and Piercings. Legislation in the United States
Fig. 1.4 A semi-nomadic Masai woman from Entesopia-Magadi in the Rift Valley, Kenya. Photographer: Dale Glasser (with permission)
there is limited data on the absolute prevalence of these practices prior to recent years. Even today, most studies are convenience studies of particular groups, usually teenagers and young adults (Tables 1.1 and 1.2). It is by no means clear how much of these data can be generalized to a larger population even in the country of origin. The majority of studies are cross-sectional studies. One can see that in the older age groups, the practices are not common, but clearly, given the permanent nature of the attribute, tattoos are cumulative, and, with time they may be more generally distributed across the generations. Interestingly, the two identical surveys of undergraduates at Pace University, which were done in 2001 and 2006, showed no change in the prevalence of both tattooing and body piercing and similar results were found when Harris Poll looked at tattooing in representative samples of the American population in 2003 (16%, phone survey, data not shown) and 2008. It is too soon to know whether this means that in the United States of America the numbers of those interested in these forms of body modification have reached a plateau or even peaked.
5
In general, the numbers of women with tattoos are fewer than men with tattoos, but the figures are approaching equality. Eighty percent of the women have tattoos that are smaller than the palm of the hand and that figure is only 56% for the men. Also 90% of the tattooed men, but only 48% of the tattooed women, have an easily visible tattoo, that is a tattoo on the face, neck, arms, hands, fingers, legs, ankles, feet, or toes. The data are different for body piercings. Body piercing, as we now recognize it, was hardly seen before the end of the 1980s, so that earlier surveys only relate to soft earlobe piercing. Figures for this latter activity are fairly consistent. Between 30 and 35% of the general population and up to 50% of women have soft earlobe piercings. Some of the more recent body piercing surveys separate soft earlobe from hard cartilage piercings, others include soft earlobe piercings in men only, and others do not make any distinction. The 2008 Harris Interactive Poll, mentioned previously, found that 50% of adults aged 18 and over have ear piercings. Body piercing over all, even excluding soft earlobe piercing, is more common in women than in men. The second study in Table 1.2 where this was not the case was based on a biased clinic sample with 78% of females and only 22% of males. The piercings are in easily visible locations in nearly all men with body piercings, whereas this is only the case in 77% of the women. Covered piercings include nipple (Fig. 1.5), umbilical (common in women), and genital piercings. Although both body piercing and tattooing come under the general appellation of body modification, only one-third of those with a tattoo and approximately half of those with a body piercing, excluding the soft earlobe, have both forms of decoration. Other forms of body modification, such as branding, inserting steel balls under the skin (Fig. 1.6), embedding jewelry under the conjunctivae, or even splitting the tongue are much rarer. It appears that there are different motivations and meanings behind the two activities. In the recent past, a soft earlobe piercing in a man might have signified homosexuality. Nowadays, this is not the case, although it is rare to see a lower back tattoo in a man unless he is committed to same sex sex. Of course, a tattoo or a brand may signify the membership of an organization, for instance, the membership in a college fraternity or a street gang, whereas the insertion of body piercings has not, in general, been used that way. Tattoos may be applied in prison (Fig. 1.7), whereas a simple body piercing does not usually occur, as the inserted jewelry would be rapidly confiscated by the
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Table 1.1 Tattoo prevalence in various countries Country sample Year of sample United States of America Nationally representative school-based [35]
Patients presenting at an Emergency Department [36] Randomly selected undergraduates at Pace University [37] Adolescent clinic for dependent children of military personnel [38] General population representative sample [21] Randomly selected undergraduates at Pace University [39] General population representative on phone [40] Nationally representative on-line (Harris Poll) [41]
Germany General population representative sample [42, 43] Italy School children [Eurispes] Representative sample of high school Students in Cagliari [44] Canada Representative sample of high school students in Quebec [45, 46] Australia General population representative sample [47] Brazil Representative sample of adolescents in two public schools [48]
N
Age (years)
Total (%)
Males (%)
Females (%)
1995
5837
4.2
294
2001
454
4.6 0.5 2.6 7.6 35 28 5 23
4.8
1999
11–21 11–13 14–16 17–21 16–35 36–50 51–65 Mean 21
35 28 5 22
35 28 5 26
2001
484
16.6
500
26
22
2006
661
13.2 2 26.3 24 36 24 15 21.8
8.1
2004
12–22 £15 ³18 18–50 18–29 30–40 41–50 Mean 21
23
21
2006
1501
–
2302
36 40 10 14 9 32 25 12 8
–
2008
18–25 26–40 41–64 18–64 18–24 25–29 30–39 40–49 50–64
15
13
Accepted for publication 2005
2043
14–93 14–44 25–34
8.5 15
– 22
2002 2004
3800 820
12–18 15–19 15–16 17–18 ³19
6.6 8.5 6.0 7.2 15.8
7.2 14.5
5.7 5.4
2002
2145
12–18 12–13 14–15 16–18
7.9
9.8 4 4.9 8.5
5.8 3.5 7.6 18.1
1998
10,340
³14 ~20 ~50–60
10
11.9 25
8.5 20
12–19 Mean 15.2
3.2
–
–
2003
664
5
History and Epidemiology of Tattoos and Piercings. Legislation in the United States
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Table 1.2 Piercing prevalence in various countries Country sample
Year of sample
N
Age (years)
Total (%)
Males (%)
Females (%)
1996ª
4337
13–18
4.3ª
1.5ª
7.2ª
2000b
225
12–21
48b
54b
46b
2001b
454
Mean 21
51b
42b
60b
2004
500
21c 49f
661
35c 34f 32c 13c 2c 51b
8c 19f
2006b
18–50 18–50 18–29 30–40 41–50 Mean 21
36b
62b
2002c
2145
12–18 12–13 14–15 16–18
27.6c
10.6c 9.4c 9.0c 13.7c
43.6c 29c 44.5c 55.5c
Accepted for publication 2005c
2043
14–93 14–24 14–44
6.8c
–
2002d
234
Mean 20.6
3.4d
0d
4d
2002c
7457
16–20
20.2c
7.4c
33.8c
2004ª
817
15–19 15–16 17–18 ³19
20.3ª 20.7ª 19.3ª 23.1ª
18.4ª
21.3ª
England General population representative sample [53]
2005c
10,503
³16 16–24 25–34 35–44 45–54 55–64 ³65
10c 27c 18.7c 2.8c 2.8c 1c 0.3c
5c 13c
14.6c 46c
Australia General population representative sample [47]
1998
10,340
³14 ³14 14–23 24–33
31.5e 6.7c
18.2e 6.5c 25e 30e
44.4e 7.0c 70e 70e
2003c
664
12–19 Mean 15.2
6c
–
–
1999c
966
26
19c
9c
29c
United States of America Nationally representative school-based [49] Adolescents presenting to an urban Hospital-based clinic [50] Randomly selected undergraduates at Pace University [37] General population representative sample [21]
Randomly selected undergraduates at Pace University [39] Canada Representative sample of high school students in Quebec [45, 46] Germany General population representative sample [42, 43] Finland Students at dental visit [51] Switzerland Multicenter Adolescent classroom questionnaire [52] Italy Representative sample of high school Students in Cagliari [44]
Brazil Representative sample of adolescents in two public schools [48] New Zealand Cohort living in Otago age 3 in 1975–76 [54] a
Excludes the ear Excludes earlobe piercing in females c Excludes earlobe piercing d Oral piecing only e Pierced ears f Soft earlobe pierced b
38c 14c
8
guards. On the other hand, a tattoo once placed is not easily removed. There are a number of cultural traditions, for instance, among Hispanic peoples and among Indian Hindus, where babies’ ears are pierced soon after birth, but in general, tattoos are not even considered until puberty. It is true that nearly all those with either a tattoo or a body piercing have close friends or family with a similar characteristic, but it is not true that most people initially choose to apply these forms of body decoration when they are drunk or high. Often
Fig. 1.5 Nipple piercing. This is more common in men than in women
Fig. 1.6 Steel balls inserted under the skin of the forearm of a man preparing a woman for a suspension
A. E. Laumann
considerable thought has gone into the idea. Both activities involve pain during the application and this may add to the significance of the event. Studies, mainly in the United States of America but also in some European countries, have looked at various personality characteristics associated with tattooing and body piercing [22–26]. Adolescents and young adults who have these body modifications may describe themselves as more adventurous, creative, artistic, and individualistic than their peers, but they are more likely to play truant from school, be arrested for criminal activity, be drinkers, use illegal substances, have multiple sexual partners, and to suffer from various psychiatric disorders, including, particularly among the body pierced, clinical depression. Reasons for getting body art include not only as a fashion statement, but often as an expression of independence and self-validation. This may relate to reduced social integration, as indicated by the finding in a number of studies that those with tattoos or body piercings often do not have a strong religious affiliation. Association with risky, rather than deviant behavior, is emphasized by studies among military recruits revealing that up to a third of those with tattoos obtained them prior to joining the military [27, 28] (Fig. 1.8). Clearly, volunteering for military duty is, in itself, a risk-taking activity, but these individuals a
History and Epidemiology of Tattoos and Piercings. Legislation in the United States
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It should be noted that, although all the above associations are real, and finding a tattoo or a body piercing on an individual should send a signal to the alert clinician, as these activities have become more mainstream, any single association is less likely to be relevant.
1.3 Legislation in the U.S
Fig. 1.7 This tattoo was applied in prison
Fig. 1.8 Tattoo placed in 1943 at the age of 16 prior to joining the army. Mom is in the heart. Below is a wreath, an American eagle, a peace arrow, and God Bless America
also more likely to partake in other risk-taking activities such as smoking, drinking heavily, or being willing to ride in a car driven by an inebriated individual than their nontattooed counterparts.
As the numbers of tattoos and piercings have increased in the population, there has been call for more regulation of the body art industry [29]. Unfortunately, new rules are usually a reaction to a concern related to a local disease outbreak or an individually specific event rather than a general regard for the health of the population at large. Codes are variable from state to state; where they exist, they are rarely enforced. Interestingly, a large incidence of hepatitis B (30 cases) resulted in New York City banning tattooing in 1961 [30]. The ban was rescinded in 1997 when it was realized that tattoo establishments were operating in the city without authorization. In 1979, only three states had standards or inspections and seven states prohibited tattooing completely [31]. During the past 25 years, the trend in a number of states has been to permit tattooing and body piercing by licensed tattoo artists and body piercing practitioners [32], and in 1999 the National Environmental Health Association published a model code as a suggested basis for regulation [33]. Now at least 48 states have some form of regulation, although this is highly variable, and the rules are constantly changing [34]. A court ruling in Massachusetts in 2000 held that the right to have a tattoo is protected by the first amendment of the U.S constitution and thereby struck down the statutory requirement that only physicians be allowed to provide tattoos. Eight states require the reporting of adverse events and a number of states prohibit tattooing of persons suspected to be under the influence of drugs or alcohol. At least 18 states prohibit the tattooing or piercing of anyone under the age of 18 and other states allow it, but only with parental presence or written consent. Certification, licensing, and the successful performance on examinations are required in a few states and some require documentation of attendance at a training program in sterilization techniques. Facility regulation and certification requirements likewise vary from state to state and only some states have specific requirements or prohibitions for temporary studio locations, such as in a stall at a street fair.
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Illinois is an example of the ongoing changing regulatory scene. The legal age for getting a tattoo was reduced from 21 to 18 years in 2005, but regulations related to licensing and hygiene of the facilities were only enacted starting in July 2007. This was the result of an ongoing shortage of blood donations, as the American Association of Blood Banks standards require a 12-month deferral of blood donation after the nonsterile skin penetration with instruments or equipment, including those used for tattooing and body piercing, unless it is done by a state-regulated entity with sterile needles and non re-used ink. In general, regulations related to body piercing lag those related to tattoos, partly because of the more recent popularity of the practice and partly because a body piercing is a very quick event and, as such, hard to supervise. Body piercing regulations are often an afterthought added to those for tattooing. The Association of Professional Piercers is an international nonprofit association dedicated to the dissemination of vital health and safety information related to body piercing. It publishes information on piercing aftercare, troubleshooting, choosing a piercer and jewelry standards. Interestingly, as tattooing and body piercing have become more mainstream, employers and the military have found it necessary to be very specific about their regulations. For instance, since early 2007, large and elaborate tattoo designs were banned in the marines, and more recently, the assignments of those who already had these decorations were limited, such that they may not serve as recruiters or security guards because of their daily dealings with civilians. Similarly, many service industry employers prohibit visible tattoos and piercings among those employees who deal with the public. It is not uncommon to be served by a waitress who has covered the outer end of her eyebrow with a band-aid to hide the hole made for an appropriate jewelry piece. Currently, in the United States tattoo pigments are considered cosmetics and are approved for application on to, rather inside, the skin. The Food and Drug Administration has not approved any pigments for injection into the skin. Following reports of bad reactions, some products have, in fact, been banned from importation or removed from the market. Meanwhile under the auspice of the National Center for Toxicological Research, there is ongoing investigation into the toxic or carcinogenic potential of some of the pigments, including the commonly used titanium dioxide, when exposed to light or in photo-exposed skin.
A. E. Laumann
Similarly, unlike in Europe, there is no regulation of the metals used in the jewelry left in the skin after a piercing procedure.
1.4 Conclusion Tattooing has been widely practiced across the world and in all eras. At times, it has been associated with criminality and punishment, and used for the identification of slaves and prisoners. In other societies and at other times, tattoos have been a marker of social status and religious affiliation. Body piercing has a more limited history, although there is evidence, in ancient societies, of its use in the soft earlobe, lower lip, and nasal septum for the insertion of decorative pieces, as well as its use in the genital area for sexual inhibition or pleasure. Encouraged by modern sophisticated techniques, both tattooing and body piercing are in the mainstream of fashion in first world countries. It is unclear whether this is a passing fad or an ongoing process. In the fairly recent past, having a tattoo or a body piercing was a sign of marginality. Nowadays, the more extreme among us need to resort to even more daring insertion practices to maintain their individuality. In the United States of America, there has been increasing legislative activity, but it still varies widely from state to state. Where there are regulations, these are not always enforced and they do not necessarily address the important problems of the spread of infectious disease, the allergenic potential, or the carcinogenicity of the inserted materials.
References 1. Sperry K (1991) Tattoos and tattooing. Part I: History and methodology. Am J Forensic Med Pathol 12:313–319 2. Dorfer L, Moser M, Bahr F et al (1999) A medical report from the stone age? Lancet 354:1023–1025 3. Lowenstein EJ (2004) Paleodermatoses: lessons learned from mummies. J Am Acad Dermatol 50:919–936 4. Isaiah (44:5) The Bible 5. Leviticus (19:28) The Bible: King James Version 6. Scheinfeld N (2007) Tattoos and religion. Clin Dermatol 25:362–366 7. Reed C (2000) Tattoo in early China. J Am Orient Soc 120:360–376
History and Epidemiology of Tattoos and Piercings. Legislation in the United States 8. Demello M (2007) Encyclopedia of body adornment. Greenwood Press, Westport 9. Rockwell N (1944) Cover page. Saturday Evening Post 216:1 10. Wolf EK, Laumann AE (2008) The use of blood-type tattoos during the cold war. J Am Acad Dermatol 58:472–476 11. Papachristos A (2005) Gang world. Foreign Policy 147: 49–55 12. Steward S (1990) Bad boys and tough tattoos. Harrington Park Press, Binghamton 13. Beckwith C, Fisher A (1991) The eloquent surma of Ethiopia. Natl Geogr Mag 179:77–91 14. Waugh M (2007) Body piercing: where and how. Clin Dermatol 25:407–411 15. Daniélou A (1994) The complete kama sutra. Part Street Press, Rochester 16. Ng KH, Siar CH, Ganesapillai T (1997) Sarcoid-like foreign body reaction in body piercing: a report of two cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 84:28–31 17. Gröning K (2002) Decorated skin. Thames and Hudson, New York 18. Kanee B (1950) Technic of ear piercing. Arch Derm Syphilol 61:502 19. Lerner C (1932) History of feminine beautification. Arch Derm Syphilol 26:1022–1031 20. Stirn A (2003) Body piercing: medical consequences and psychological motivations. Lancet 361:1205–1215 21. Laumann AE, Derick AJ (2006) Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol 55:413–421 22. Armstrong ML (1994) Adolescents and tattoos: marks of identity or deviancy? Dermatol Nurs 6:119–124 23. Brooks TL, Woods ER, Knight JR et al (2003) Body modification and substance use in adolescents: is there a link? J Adolesc Health 32:44–49 24. Carroll L, Anderson R (2002) Body piercing, tattooing, selfesteem, and body investment in adolescent girls. Adolescence 37:627–637 25. Ceniceros S (1998) Tattooing, body piercing, and Russian roulette. J Nerv Ment Dis 186:503–504 26. Drews DR, Allison CK, Probst JR (2000) Behavioral and self-concept differences in tattooed and nontattooed college students. Psychol Rep 86:475–481 27. Armstrong ML, Murphy KP, Sallee A et al (2000) Tattooed army soldiers: examining the incidence, behavior, and risk. Mil Med 165:135–141 28. Stephens MB (2003) Behavioral risks associated with tattooing. Fam Med 35:52–54 29. Healy B (2008) The dangerous art of the tattoo. US News World Rep 145:69 30. Silvers DN, Gelb H (1991) The prohibition of tattooing in New York City. Am J Dermatopathol 13:307–309 31. Goldstein N (1979) Laws and regulations relating to tattoos. J Dermatol Surg Oncol 5:913–915 32. Tope WD (1995) State and territorial regulation of tattooing in the United States. J Am Acad Dermatol 32:791–799 33. National Environmental Health Association? (1999) Body art: a comprehensive guidebook and model code. National Environmental Health Association, Denver 34. Armstrong ML (2005) Tattooing, body piercing, and permanent cosmetics: a historical and current view of state regulations, with continuing concerns. J Environ Health 67:38–43; 54; 53
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35. Roberts TA, Ryan SA (2002) Tattooing and high-risk behavior in adolescents. Pediatrics 110:1058–1063 36. Rooks JK, Roberts DJ, Scheltema K (2000) Tattoos: their relationship to trauma, psychopathology, and other myths. Minn Med 83:24–27 37. Mayers LB, Judelson DA, Moriarty BW et al (2002) Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 77:29–34 38. Carroll ST, Riffenburgh RH, Roberts TA et al (2002) Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Pediatrics 109:1021–1027 39. Mayers LB, Chiffriller SH (2008) Body art (body piercing and tattooing) among undergraduate university students: “then and now”. J Adolesc Health 42:201–203 40. Pew Research Center (2007) How young people view their lives, futures and politics. Pew Research Center, Washington 41. http://www.harrisinteractive.com/harris_poll/index. asp?PID=868 42. Stirn A, Brahler E, Hinz A (2006) Prevalence, sociodemography, mental health and gender differences of tattooing and body piercing. Psychother Psychosom Med Psychol 56: 445–449 43. Stirn A, Hinz A, Brahler E (2006) Prevalence of tattooing and body piercing in Germany and perception of health, mental disorders, and sensation seeking among tattooed and body-pierced individuals. J Psychosom Res 60:531–534 44. Preti A, Pinna C, Nocco S et al (2006) Body of evidence: tattoos, body piercing, and eating disorder symptoms among adolescents. J Psychosom Res 61:561–566 45. Deschesnes M, Demers S, Fines P (2006) Prevalence and characteristics of body piercing and tattooing among high school students. Can J Public Health 97:325–329 46. Deschesnes M, Fines P, Demers S (2006) Are tattooing and body piercing indicators of risk-taking behaviours among high school students? J Adolesc 29:379–393 47. Makkai T, McAllister I (2001) Prevalence of tattooing and body piercing in the Australian community. Commun Dis Intell 25:67–72 48. Oliveira MD, Matos MA, Martins RM et al (2006) Tattooing and body piercing as lifestyle indicator of risk behaviors in Brazilian adolescents. Eur J Epidemiol 21:559–560 49. Roberts TA, Auinger P, Ryan SA (2004) Body piercing and high-risk behavior in adolescents. J Adolesc Health 34: 224–229 50. Gold MA, Schorzman CM, Murray PJ et al (2005) Body piercing practices and attitudes among urban adolescents. J Adolesc Health 36(352):e17–e24 51. Venta I, Lakoma A, Haahtela S et al (2005) Oral piercings among first-year university students. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 99:546–549 52. Suris JC, Jeannin A, Chossis I et al (2007) Piercing among adolescents: body art as risk marker. J Fam Pract 56: 126–130 53. Bone A, Ncube F, Nichols T et al (2008) Body piercing in England: a survey of piercing at sites other than earlobe. BMJ 336:1426–1428 54. Skegg K, Nada-Raja S, Paul C et al (2007) Body piercing, personality, and sexual behavior. Arch Sex Behav 36: 47–54
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Materials Used in Body Art Christa De Cuyper and Davy D’hollander
Core Messages
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Body art is increasingly popular, resulting in the raising occurrence of complications and adverse reactions, some of them related to the substances used. To identify the causative agent, it is essential to know the exact composition and nature of the materials applied. Nickel allergy is the most common complication of body piercing and can easily be avoided by the use of ornaments made of high-grade stainless steel or inert plastic material. Tattoo compounds in comparison to cosmetics are in general not officially controlled. Moreover, the origins as well as the chemical and toxicological specifications of these colouring agents are hardly known by the producers, the performers and by the consumers. From the medical perspective, uniform worldwide regulation would certainly offer opportunities to reduce the risks and complications involved in the use of chemical components that might be potentially hazardous and may threaten the health of the tattooed individual with special concern for heavy metals and carcinogenic aromatic amines. Recent studies have demonstrated that sunlight exposure and laser treatment of tattoos can induce decomposition products with carcino-
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genic properties. The clinical implications of these findings have not yet been identified. Recommendations on the hygienic conditions of piercing and of the application of tattoos and permanent make up (PMU) are available. Respecting these guidelines could minimise the risk of transmission of infectious diseases. The occurrence of contact allergy to temporary (henna) tattoos is linked to the presence of PPD in high concentration.
2.1 Introduction Body art has become increasingly popular in the last decades resulting in the raising occurrence of complications and adverse reactions, some of them related to the procedures, other side effects caused by the substances used. In order to identify the causative agent it is essential to know the exact composition and nature of the materials applied. Although a lot of research has been done in this field, there is still a lack of uniform worldwide regulation on the procedures and materials. This chapter will give an overview of materials used nowadays in the different forms of body art.
2.2 Piercings 2.2.1 Materials C. de Cuyper () Department of Dermatology, AZ Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium e-mail:
[email protected] A diversity of materials has been used over the centuries. Natural materials such as wood, ivory and bones
C. de Cuyper, M. L. Pérez-Cotapos S. (eds.), Dermatologic Complications with Body Art, DOI: 10.1007/978-3-642-03292-9_2, © Springer-Verlag Berlin Heidelberg 2010
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C. de Cuyper and D. D’hollander
Fig. 2.1 Traditional golden piercing
have always been popular in tribal, religious and ritualethnic piercings (Fig. 2.1). Large ranges of metals (copper, silver, gold, iron) have been recovered in excavations. Earrings like most jewellery were often made of silver and gold, pearls and precious stones, but in recent times many cheap jewels are just made of plated nickel. Most common materials used nowadays for piercing or embedding are stainless steel, titanium, niobium, gold, glass and plastics (Figs. 2.2 and 2.3; Table 2.1). Different qualities of stainless steel are produced. To check if number 316 grade steel corresponds to the requirements, International Organization for Standardization (ISO) [1] and American Society for Testing and Materials (ASTM) [2] standards can be used. Stainless steel is specified with letters and numbers, letter L corresponding with low carbon (higher corrosion resistance) and VM signifying vacuum arc remelted (a technique used to improve homogeneity, with better crystalline structure and mechanical properties); number 316 grade steel corresponds with this composition (Fe,
