When Adolescents Want Tattoos or Piercings

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The Checkup

When I was reviewing for my recertification exam recently, I gave the wrong answer to a question about an infected ear. Not a standard inner ear infection; this was a painful red swollen outer ear, in an 18-year-old. I thought she had a skin abscess, and said to put her on antibiotics for standard skin organisms. Wrong. The adolescent in the problem had recently had a high piercing done, through the cartilage up toward the top of her ear, and she had perichondritis, an infection of the tissue layer that surrounds and nourishes that cartilage.

The correct answer was to give her antibiotics that cover Pseudomonas, a particularly nasty bacteria that can live in the external ear canal, but rarely causes any kinds of problems in immunologically normal people.This would be a very bad infection to miss or misdiagnose, since it could go on to cause bad damage to the cartilage itself, leading to deformity of the ear.

On Monday, the American Academy of Pediatrics released its first clinical report on tattooing, piercing and scarification in adolescents and young adults, including a close examination of the medical literature on these increasingly prevalent and increasingly mainstream forms of “body modifications” or “body art.”

High ear piercings are now common, as are nose piercings and other body piercings. The perichondritis question was included in my review materials in part to remind pediatricians that our adolescent patients may well be considering decorating or modifying their bodies; a Pew Research Center report cited in the new A.A.P. report said that in 2010, among 18- to 29-year-olds, 38 percent had at least one tattoo and 23 percent had a piercing somewhere other than the earlobe.

Tattoos, which were once viewed in pediatrics as evidence of a somewhat marginal and high-risk lifestyle, have become sufficiently mainstream that it is now possible to hear college students talk of marking their individuality by not getting tattooed. So many young people have tattoos that in 2015 the military relaxed the rules against them, which were discouraging too many potential recruits — though there are still restrictions against offensive tattoos or most that would be visible in uniform.

One of the report’s lead authors, Dr. Cora Collette Breuner, who is a professor of pediatrics and adolescent medicine at Seattle Children’s Hospital, and the chairwoman of the A.A.P. Committee on Adolescence, said, “It should be brought up at adolescent visits: ‘Have you considered getting a tattoo, a piercing, where?’” Pediatricians should be asking questions like, “Have you talked to your parents? Do you understand it’s permanent?” Dr. Breuner suggests that a child who wants a tattoo might consider a temporary tattoo first to see what it’s like to walk around with the decoration; parents can also suggest a waiting period, even for a young adult, before going ahead.

And the somewhat fraught area of “body modification” and “body art” can become an arena for discussing the nature of permanent decisions, body autonomy and personal health.

Opening the conversation could be an opportunity to emphasize the permanent nature of a tattoo (the report goes into the difficulties and the expense of tattoo removal, and also the limited success in many cases), and also to bring up the question of how a visible tattoo or piercing could affect employment opportunities later on. (And it’s not just a question of not being able to get a job in a more conservative setting; I recently heard about young actors with tattoos who have to show up extra early to get their tattoos covered with body makeup, or who sometimes get passed over for parts.)

“I don’t think health care practitioners should be critical or judgmental,” Dr. Breuner said. “That just drives the whole thing back into the alley.”

Doctors should urge teenagers considering tattoos or piercings to have these conversations with their parents, and to make sure that anything that gets done is done in a licensed and sanitary place, and that tetanus immunizations are up-to-date. And for adolescents who have had issues in the past with scarring, or who may have compromised immune systems — those who have lupus, for example, or those who have had cancer and may want a tattoo at the site of a scar — it’s an opportunity to review why this may be higher risk.

The legal rules on minors getting tattoos and body piercings vary from state to state; some states prohibit it outright, others allow it with parental consent, and still others require parental presence. But ideally, Dr. Breuner said, this should not just be a conversation in which a parent says ‘Absolutely not,’ and a child hears, ‘I just have to wait till I’m old enough.’ Instead of that firm no, especially with older adolescents, parents should consider offering “a firm maybe, let’s get more information so you don’t do something you wish you hadn’t done.”

When her own daughter, at 18, went to get her belly button pierced five years ago, Dr. Breuner accompanied her. “It wasn’t like I condoned it or hated it — I just wanted to be there to support her,” she said. “I wanted to make sure it was clean and sterile, and it was,” Dr. Breuner said. Sterile procedures were strictly observed, she said, including three changes of gloves. “I asked the guy, ‘What did you do before,’ and he was a surgical tech.”

But germs can get in when the skin is pierced, and one important role for doctors is to manage infections or complications. And there are certainly health considerations to be aware of — like the risks of skin infections after tattoos and piercings, but also including the transmission of blood-borne diseases such as hepatitis C if sterile procedures are not followed carefully All the risks are much higher with amateur tattooing and piercing than with licensed professionals.

When going to get a tattoo or a piercing, the report recommends, look for such evidence of sterile procedures as the use of new gloves, new needles or piercing equipment removed from sterile containers, and fresh ink poured into a disposable container for each new customer.

Reputable professionals should provide ample follow-up instructions, which should be carefully read and followed. Watch for the signs of infection, redness, swelling, any evidence of pus or drainage, and of course, fever, and red streaking lines on the skin. If a recent piercing continues to bleed, it may be that a blood vessel was hit and it isn’t clotting properly. All of these problems should be seen by a doctor — and ideally the doctor will be up on my test question and others like it.

It’s also important to keep up the vigilance; body piercings can take much longer to heal than many teenagers realize — the eyebrow, for example, takes six to eight weeks, but the navel can take up to nine months. Many body piercings have other implications for health, from the tooth chipping associated with tongue piercings (not to mention the risk of a piece of jewelry getting into the airway) to the problems with later breast-feeding that can follow nipple piercings.

I have taken care of teenagers with tongue piercings, and my general reaction, I have to admit, is: “Oh, yuck.” But as Dr. Breuner said, “Our job as pediatricians is to be sure our kids are taken care of.” And part of our job as parents is to help our adolescent children negotiate the complex journey to full adulthood and autonomy, which includes taking care of themselves.