Piercing Complications

Presentation

A patient presents with pain and redness around the piercing site. Upon inspection, there is erythema and some purulence coming from the piercing. The patient is afebrile and denies any other symptoms.

Piercing complications typically fall into two categories: infection or inability to remove. As infections lead to swelling, the edematous surrounding tissue may encase the piercing.

The more usual sites of piercing include ears, eyebrows, glabella, nasal septum, nostrils, lips, tongue, face, mouth ( Fig. 150.1 ), chin, nipples ( Fig. 150.2 ), navel, male and female genitalia, digits, and pocketing or flesh (skin) stapling. There may be a single piercing or multiple piercings. The prevalence of abnormal tooth wear or tooth chipping/cracking is greater for tongue piercing than lip piercing (see Chapter 50 ).

What to Do

• Obtain a history regarding the piercing , including how long it was inserted, any recent removal, postpiercing care, and onset of symptoms.

• Review with the patient and in the chart any prior methicillin-resistant Staphylococcus aureus (MRSA) exposure or infection.

• Screen the patient for immunocompromising conditions (diabetes, steroids, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), chemotherapy, etc.).

• For new piercings , screen if the tetanus vaccination status is up to date, and vaccinate if indicated.

• Piercings that are infected should be removed. For new piercings, this may mean that the pierced canal will close. However, the foreign body will serve as a nidus for the infection, as it cannot be cleared by the patient’s immune system.

• Provide appropriate analgesia. For piercings in the ear, a great auricular block with bupivacaine 0.5% will provide anesthesia without distorting tissues by avoiding infiltration of local anesthetic near the piercing.

• Removal of the piercing depends on both type and location. If a hoop cannot be opened for removal , it should be cut in a single location and the free ends bent in opposite directions orthogonal to the two-dimensional plain of the hoop. This allows for easier repair by a jeweler in case the hoop is of large financial or sentimental value.

• If a stud piercing cannot be removed , the locking mechanism that could not be opened by hand may be opened with hemostats. Hold the front of the stud with one hemostat and use the second hemostat to loosen the back. This may damage the stud.

• Remember that some studs have flat backs, whereas others have screw backs that require twisting. When available, compare the stud to its twin.

• If the back cannot be removed , the shaft of the stud must be cut. This can be done with sturdy wire cutters, ring cutters, and some trauma shears.

• Ear studs may be embedded when the anterior portion of the stud gets pushed posteriorly into the earlobe. To remove an embedded ear stud, remove the back (or cut the shaft if needed). After good local anesthesia , unroof the area over the front of the ear stud. Holding the ear lobe, gently push the stud anteriorly by grasping the shaft with a hemostat. Grab the stud as it exits the anterior side of the ear lobe before letting go of the shaft with your hemostat.

• Transdermals or microdermals are small implants that consist of a footplate and a post in the shape of the letter L. The post protrudes from the skin’s surface and is held in place under the dermis by the small, flat foot plate. Provide local anesthesia with injection of lidocaine. Grasp the outside part of the microdermal with forceps or a hemostat and gently elevate and move the microdermal until the direction of the foot plate can be determined. Using a scalpel, make a small (∼2-mm) incision going away from the shaft on the opposite side of the foot plate. Tilt the microdermal toward the foot plate while holding down the surrounding tissue until it releases and comes out.

• Sometimes removal of the piercing and application of warm compresses suffices to allow the infection to subside. Otherwise , provide oral antibiotic coverage for staphylococcus and streptococcus, and expand to MRSA coverage in patients known to be colonized.

• The most common pathogen in infected cartilage piercings (nose, ears [does not include earlobe]) is pseudomonas. Ensure appropriate antibiotic coverage.