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The Journal of School Nursing

DOI: 10.1177/105984050101700103 2001; 17; 12 J Sch Nurs

Myrna L. Armstrong and Lynne Kelly Tattooing, Body Piercing, and Branding Are on the Rise: Perspectives for School Nurses

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CONTINUINGEDUCATION

The Journal o f School Nursing provides readers the opportunity to earn Continuing Education credit. In order toreceive credit, read this article, take the test found at the end of the article, and return the test and CE form asinstructed.

OBJECTIVES:

Upon completion of this continuing education feature, the school nurse will be able to:

1. Describe existing regulations for body artists.2. Discuss the physical and psychosocial risks involved with various body art procedures.3. Recommend appropriate aftercare for teens who have body art.4. Outline the role of the school nurse in educating students, staff, and the community about body art proce-

dures, aftercare, and policies regulating body art practices.

Tattooing, Body Piercing, and BrandingAre on the Rise: Perspectives forSchool Nurses

Myrna L. Armstrong, RN, EdD, FAAN; and Lynne Kelly, RN, MSN

Myrna L. Armstrong, RN, EdD, FAAN, is a professor at the school of nursing, Texas Tech University Health Sciences Center, Lubbock, TX.She has published numerous articles and has prepared educational materials for students on tattooing and body piercing.

Lynne Kelly, RN, MSN, has been a school nurse at a middle school and high school in Austin, TX. Currently, she is an instructor at theschool of nursing, Texas Tech University Health Sciences Center, Lubbock, Texas.

ABSTRACT: This journal presented the first nursing information on adolescents and tattooing 6years ago, and 5 years ago, information was provided about body piercing. These were publishedto help school nurses assist adolescents become informed decision makers. Another purpose wasto prevent risks and, if possible, help dissuade adolescents from tattooing and body piercing.Continuing this theme, the latest information and trends are reported and discussed, and newinformation on scarification and branding is presented. If an adolescent wants some form of bodyart (tattooing, body piercing, or branding), they will often obtain it regardless of regulations, risks,or money. School nurses can take a powerful, proactive role by sharing applicable information,realistic concerns, and care instructions about tattooing, body piercing, and branding. Specificinformation, risks, and care about each form of procedure is presented. A convenient referencetable is available for nurses and students. Additionally, nursing actions are suggested includingmaking changes in health policies regarding body art on a local and state level.

KEY WORDS: body art, branding, health education, health regulations, high-risk behavior, bodypiercing, tattooing



13

INTRODUCTION

These are just a few of the stories school nurses de-scribe. Have you experienced this? A 14-year-old stu-dent comes into your clinic sporting a freshly appliedtattoo. Upon questioning you find out that he ob-tained it that week from a person who just purchaseda house across the street from the school and has justopened a tattoo studio. The student said many kidshave been over there to visit the studio and are excitedabout getting the tattoos they have always wanted.

Or, a 12-year-old student asking to see you &dquo;in pri-vate&dquo; so she can show you her week-old self-inflictednavel piercing that is reddened and crusted with pu-rulent drainage. She begins to cry because she has hada great deal of pain and frustration with the piercing.

Or, the panic-stricken 16-year-old student seekingyour advice for his swollen tongue from his day-oldtongue piercing. Upon examination, the skin seems tobe growing over the shank that was inserted after thepiercing. When asked if the student had talked to thepiercer about the procedure, the student said the artisttold him this was his first tongue piercing, but he &dquo;act-ed&dquo; like he knew what he was talking about becausehe does tattooing all the time.

BODY ART IS ON THE RISE

Body art is not going away. In fact, traditional tat-tooing and body piercing seem to be increasing, asdoes branding. Additionally, there seems to be morecreativity and risk taking, especially with body pierc-ing, in an attempt to see what kind of unusual pierc-ings can be created. Examples include piercings on thelateral neck, the cheek, the uvula, the lips, over thespinal cord, in the tragus of the ear, on the chest, and3-D implants under the skin.The increasing number of studios and the increas-

ing amounts of pigment purchases indicates that thistype of business is on the rise (Anderson, 1992). Onelarge national supplier of tattooing accessories claimsmore than 37,000 regular customers (Tope, 1995).Documented adolescent interest regarding tattooing isas high as 55% (Armstrong & McConnell, 1994b;Armstrong & Pace-Murphy, 1997). No national pollshave been conducted; therefore, firm numbers on theamount of body art recipients-adolescent or adults-are not documented. Yet, just looking at groups ofpeople in the media, schools, or in the general public,one can see that body art is increasing. Also those dis-playing body art include a wide range of people froma variety of occupations and social classes (Armstrong,1991).Two research studies done in 1993 and 1996, which

included almost 3,000 adolescents in nine differentstates across the country, reported an 8 to 10% rate oftattooing. There were 318 (154 girls and 164 boys)who had tattoos (Armstrong & McConnell, 1994b;Armstrong & Pace-Murphy, 1997). Most of the stu-

dents were 14 to 18 years of age, and more than 60%

reported academic grades of &dquo;A&dquo; and &dquo;B.&dquo; One student

reported getting his first tattoo at 8 years of age. Otherstudies have estimated 25% of all 15- to 25-year-oldsare tattooed. Over one third (37%) of a group of 1,835U.S. Army basic recruits reported tattoos (Armstrong,Pace-Murphy, Sallee, & Watson, 2000). Although sol-diers having tattoos may sound typical, many of them(64%) obtained them before entering the military. Ofthese recruits, some (35%) reported that they obtainedthem while in high school, with 20% during their se-nior year.

Statistics published by state regarding body art alsoprovide a picture of growth. For example, the state ofTexas has been licensing tattoo studios since February1994. In the 10 months of that year that Texas li-

censed tattoo establishments, 137 artists paid theiryearly studio licensing fee of $130; by the end of 1998,there were 456 studios. This reflects a 283% increasein the number of body art studios. Constituent com-plaints about tattooing received at the Texas Depart-ment of Health in 1998 doubled from the previousyear (from 70 to 141). They also had an increase (from14 to 66) complaints about body piercing at a timewhen Texas did not even have regulations to licenseand review body piercing procedures. Since that time,the state of Texas has enacted legislation for bodypiercing and has increased their yearly licensing feefor tattoo studios to $450 to further finance investi-

gations of complaints. When artists practice both tat-tooing and body piercing in the same studio, as many(85%) in Texas do, the yearly licensing fee is $600.

LEGISLATION AND REGULATIONS

The amount of legislation surrounding body artpractices in individual states is changing in responseto client safely concerns. Trying to stay on top of thelatest body art regulations can be difficult, however,because the information from the states continues to

change. While the amount of legislation is increasing,the universal strength of those regulations still variesfrom state to state. In 1995, seven states prohibitedtattooing entirely, and 20 prohibited tattooing indi-viduals under the age of 18; virtually no state hadbody piercing stipulations (Tope, 1995). In 2000, ninestates (Alaska, Arkansas, Hawaii, Kansas, Massachu-setts, New Hampshire, Oregon, Rhode Island, andSouth Carolina) include either an examination of art-ist’s knowledge and or documented experience andtraining (see Table 1). Although 14 states still do nothave state regulations, some have specific city or

county ordinances. Additionally, 17 states have addedlegislation that governs the practice of body piercing(California, Delaware, Florida, Illinois, Indiana, Iowa,Kansas, Maine, Maryland, Michigan, Missouri, NewHampshire, New Jersey, Ohio, Oregon, Texas, and Wis-consin), and several others are considering new regu-



14

Table 1 State Regulations Regarding Tattooing and Body Piercing as of January 1999

lations. Overall, the states of Kansas and Oregon seemto have the most comprehensive set of regulations inthe nation for body artists; they require an examina-tion, documentation of continual training, as well ascontinuing education.Many states prohibit tattooing individuals under

the age of 18, but evidence from previous studies ex-amining tattooing in adolescents documents that if anadolescent wants some form of body art (tattooing,body piercing, or branding), they will often obtain it,regardless of regulations, risks, or money (Armstrong

& McConnell, 1994b; Armstrong & Pace-Murphy,1997). &dquo;Older adolescents have cars and money to ob-tain studio tattoos whereas younger adolescents createtheir own marks or ask friends for them&dquo; (Armstrong& McConnell, 1994b, p. 187). Thus, the adolescentconsumer of body art is affected by the lack of consis-tent body art regulations and licensing standards.

Many maverick artists are present, operating inhomes, and do not operate under established stan-dards of practice and protocols. The artist’s unique ed-ucation and experience (or lack of it) often determines



15

the hygienic practices that are adopted and the skinaftercare procedures that are recommended. This be-comes a good example of an artist-consumer-regulat-ed business because, unfortunately, it is then up to theadolescent customer to ensure that sterile techniqueand proper hygiene are used, and medically sound sitecare is recommended.

MAJOR CONCERNS OFBODY ART

Four major concerns are present with body art: a)the artist and their education, b) the environment inwhich the procedure is done, c) the often unenforcedmilieu associated with the procedure to protect thepublic, and d) the equipment and associated materialsinstilled in or on the body, whether it is pigment, jew-elry, or a brand.

For the body artists, there is virtually no specificcurriculum or national body of knowledge that hasbeen developed for performing these invasive proce-dures. As noted in Table 1, few states require specificeducation on subjects such as anatomy, universal pre-cautions, disease transmission, skin diseases, steriliza-tion procedures, sanitation, personal hygiene, and af-tercare instructions, which can prevent transmissionof disease or injury (Armstrong & Fell, 2000). Oftenpeople decide to become an artist because the proce-dure looks easy, and no specific criteria are required toopen a business. Apprenticeships are seldom offeredbecause of the concern of competition upon comple-tion. Several body art associations (Alliance of Profes-sional Tattooists, American Body Art Association, As-sociation of Professional Piercers, and Society of Cos-metic Professionals) provide excellent educational ses-sions about health concerns during their nationalconferences. Unfortunately, these associations do notrepresent the majority of artists in the nation.

Body art is performed in a variety of environments.Most forms of body art are performed in a studio at apermanent address. If the state has regulations, it is

hoped that the mandates are concise about the workenvironment of the studio, such as prohibiting peopleand pets from living in the same area, adequate light-ing and ventilation, privacy for the individual havingthe procedure, as well as adequate sinks, running wa-ter, and sanitation to assure proper hygiene for theartist and cleansing of equipment. Body art proceduresare sometimes done in vans and at flea markets, rockconcerts, and as entertainment at parties. In these sit-uations, some states will issue temporary licenses tothe artists for these short-term establishments, butstringent hygiene regulations should still apply forthese portable environments and artists.A natural assumption associated with the presence

of state regulations for body art is the belief that thereis enforcement of the regulations. Yet, the amount ofenforcement that is instituted for body art studios is

not dependent on the presence of the regulations. Itdepends more on human, time, and financial resourc-es of the departments, as well as the commitment tomaking the body art industry safe. Most agencies workon complaints rather than proactively inspecting stu-dios and watching procedures. Interagency coopera-tion (i.e., health department with police) to enforceregulations also depends on the amount of legal cloutconnected with the legislation. For example in Texas,past tattoo regulations only carried a Class B misde-meanor with a meager $500 fine. Present body art in-fractions now carry a Class C misdemeanor, punish-able by a $4,000 fine, a 1-year jail sentence, or both;the addition of civil penalties now carry fines of

$5,000. With the Class C misdemeanor, the judicialsystem is able to evoke stiffer penalties and are muchhappier to cooperate in enforcement. Additionally, toclose a studio takes repeated complaints, violations,and inspections with careful documentation. Recent-ly, it has been heartening to see this is finally happen-ing in some states, but it takes a long time for theentire effort to be completed and the doors of a busi-ness establishment to be locked.

PHYSICAL AND PSYCHOSOCIAL RISKSOF BODY ART

Numerous newspapers and magazine reports, pro-ponents of body art, and even some health providerswill point to the many people with tattoos and pierc-ings who have had no side effects and proclaim thereare &dquo;no risks.&dquo; There is difficulty in making thosestatements because there is not adequate data to makethat judgment. Often the presence of no data meansthere is no risk present, but in this situation, the pres-ence of no data means there has been a lack of re-

porting the risks. Currently, no national data bases ex-ist that keep records of complications associated withthe procedures, nor are there any national agencies(such as the Centers for Disease Control and Preven-tion) that document how many cases of hepatitis B orC are associated with body art. Many health providersdo not take the time to publish, therefore most of thecomplications are not documented. For example,there was a recent tragic story of a 22-year-old grocerystore employee who obtained a $45 tattoo and neededa liver transplant approximately 4 weeks later (Shea,1998). Perhaps, with the recent work of state agenciessuch as the various departments of health that arenow registering complaints and tracking studios, moredata will be available in the future. Meanwhile, themedical literature continues to remain limited on the

subject, and reporting is found only in the letters tothe editor, not in articles (Anderson, 1992; O’Malley,Smith, Braun, & Prevots, 1998; Pugatch, Mileno, &

Rich, 1998).Additionally, it often has been reported that when

problems arise from body art, recipients first seek oth-



16

er studio artists rather than tell the originating artist(Armstrong & McConnell, 1994b; Armstrong & Pace-

Murphy, 1997). Thus, the originating artist does nothave knowledge of problems. Health providers seemto be sought later, after major problems surface or theadolescent is pressured to do so by parents or the sec-ond studio artist.

Any break in the skin can expose the individual tolocal infections, as well as systemic illnesses. With allthe forms of body art, there is a release of serosan-

guinous fluid accompanying the repetitive puncturingof tattooing, the puncture wounds of body piercing,and the application of heated steel. Physical healthproblems from body art can stem from poor artisttechnique, equipment hygiene, or localized infectionsor allergic reactions to the injected materials. Any am-ateur infliction of body art procedures can certainlyraise concerns about health risks.

Newly acquired body art, especially body piercing,for the adolescent engaged in sports activities, also hasthe potential for infections (Schnirring, 1999). Newpiercings require continual wear of the jewelry as &dquo;theskin inside the hole epithelializes,&dquo; so students play-ing contact sports need to make special efforts to keepthe site clean and dry (p. 27). The optimum recom-mendation, if the site is healed, is to remove the bodyjewelry during the actual sporting event because ofthe dirty environment and potential for trauma, aswell as the sweating that normally accompanies theevent. Friction from clothes and shearing forces alsopose abrasion hazards. If the jewelry is not removed,additional hazards such as swallowing a dislodgedtongue barbell, could be a problem.

The potential for blood-borne diseases with bodyart can affect both the clients and the artist (Long &

Rickman, 1994; Sperry, 1991). In all fairness to anytype of body art and the artist, the only way to accu-rately account for risks of body art, such as blood-borne complications, is to collect blood samples of cli-ents before entering the studio for the procedure andthen to test them frequently following the procedure.Three self-reported cases of hepatitis B were reportedby college students in a recent body art study (Greif,Hewitt, & Armstrong, 1999).

In general, hepatitis B is the major threat with bodyart because it can be transmitted in as little as 0.00004ml of blood (British Medical Association, 1990; Sperry,1991) and can survive on blood-contaminated surfac-es, such as instruments or countertops, for more than2 months. In addition, hepatitis C is now being re-ported (Shimokura & Gully, 1995). Although manystudents are vaccinated for hepatitis B, health provid-ers are calling for all body artists to be offered the hep-atitis B vaccine series (Anderson, 1992; Long & Rick-

man, 1994; National Environmental Health Associa-tion [NEHA], 1999; Sperry, 1991; Tope, 1995). For stu-dents who want any form of body art and have acongenital or chronic illness, a physician consultation

and the initiation of antibiotic prophylaxis is recom-mended before any body art procedure (Cetta, Gra-ham, Lichtenberg, & Warnes, 1999). Transmission ofHuman Immunodeficiency Virus (HIV) transmissionattributable to body art is questionable (Anderson;Sperry). One article describes an HIV occurrence in aprison (Doll, 1988) associated with tattooing, as wellas a recent case history report of HIV acquired frombody piercing (Pugatch et al., 1998).

Psychosocial risks from body art include disap-pointment, low esteem, and embarrassment becausethe recipient may not be satisfied with the product ormay be distressed by the public’s response to the bodyart (Armstrong & McConnell, 1994b; Armstrong &

Pace-Murphy, 1997). With adolescents and tattoos,this tends to happen because of the &dquo;whimsical andshort decision-making time for the tattoos, the earlyage of tattooing, the exposed body locations, the vi-sual messages of the tattoos and the lack of supportby parents and siblings&dquo; (Armstrong & McConnell, p.123).

SPECIFIC BODY ART FORMS

Currently, the most popular forms of body art aretattooing and body piercing; information on brandingwill also be presented. Each of the body art forms willbe discussed specifically by reviewing the procedureand discussing the concerns. Risks and various mo-dalities of treatment will be summarized in the textand also are presented in Table 2, available as a con-venient tear-out chart for further reference.

Tattooing

Most often, &dquo;an electrically powered vertical vibrat-ing instrument resembling a dentist drill, and contain-ing from one to fourteen solid, whisker-thin needlesjoined on a needle bar, injects the tattoo pigment 50to 3,000 times per minute up to, or into the dermis ata depth of 1/64 to 1/16th of an inch&dquo; (Armstrong,1991, p. 216). Although pain is subjective, some areaschosen for a tattoo are more sensitive, such as overjoints and the ankle. Tattoo artists are not allowed touse anesthetics. Small tattoos can be completed in lessthan an hour, but larger tattoos may be done in sec-tions and in several sittings. Reputable artists will nottattoo intoxicated people because alcohol dilatesblood vessels, producing more bleeding.

Once the tattoo is completed, the fresh tattoo is

covered with a dressing. The artist should provide spe-cific aftercare instructions for keeping the area cleanwith soap and water. Lotion is recommended to keepthe area moist to prevent drying and scabbing of thetattoo (see Table 2). &dquo;Swimming is discouraged for 3to 4 weeks either in salt, fresh, or chlorinated poolwater because the dermal pigments in new tattoosmay be inadvertently leached out&dquo; (Sperry, 1991, p.



17

318). Intense and repeated sunlight exposure will fadeany colorful tattoo.

Several problems are present with the tattoo pig-ments. First, the pigments contain nonstandardizedingredients with the exact mixtures of tattoo pigmentsconsidered part of proprietary knowledge and the art-ist’s creativity (Anderson, 1992; Sperry, 1991). Second,the pigments have been approved by the Food andDrug Administration (FDA) for topical, not interder-mal, procedures (Anderson). Thus, injecting these pig-ments into the skin can initiate allergic responses andproduce &dquo;delayed-type hypersensitivity shortly afterthe procedure or up to 17 years later&dquo; (Duke, Urioste,Dover, & Anderson, 1998, p. 488). Red pigments (mer-curic sulfide or cinnabar) seem to produce the mostallergic responses. In 1976, the FDA limited theamount of mercury to three parts per million in thistype of pigment, but reactions to the red pigment con-tinue. Another problem pigment is yellow (cadmium),which may produce photosensitivity (Armstrong,1991). Finally, the use of single-unit containers of pig-ments are recommended for tattooing. Unfortunately,as a cost-saving measure, many artists purchase largequantities of pigments. This can set up scenarios suchas when a customer arrives, a portion of the pigmentis removed from the vat. Following the tattooing, theunused portion might be returned to the original con-tainer, thus contaminating the whole amount of pig-ment ; or the remainder of unused tattoo pigmentcould be used for the next customer, thus injectingcontaminated pigment.

Health concerns related to radiologic imaging oftattooed people have been reported (Elster, Link, &Carr, 1994). At first, the reports only cited the con-cerns of magnetic resonance imaging (MRI) and eye-liners. Cosmetic eye-lining tattoos contain metallicoxides of iron or titanium, and the particles act as con-ductors and deposit heat in the local tissues. Recently,another report discusses MRI interaction with a dec-orative tattoo, again citing the iron-based pigments(Kreidstein, Giguere, & Freiberg, 1997). Persons withtattoos should be encouraged to accurately fill out anymedical history surveys for diagnostic studies to alertstaff about the presence of tattoos.

Amateur tattooing presents &dquo;even more psychoso-cial and health risks since a variety of uneven, sim-plistic marks are made with crude instruments (pen-cils, pens, straight pins, needles), pigments (charcoal,soot, mascara, or carbon), and placed on exposed bodylocations such as arms and hands&dquo; (Armstrong &

McConnell, 1994b, p. 27). These tattoos often aredone &dquo;for the fun of it&dquo; by adolescents with no accessto a studio or by gang members and adolescents witha history of incarceration. Impulsive decision makingfrequently is associated with amateur tattooing. Later,the tattoos result in more infections and often are re-

gretted, with the adolescents having more feelings ofembarrassment and low esteem (Long & Rickman,

1994). Recently, more gang-affiliated tattoo removalprograms are being initiated to remove unwanted tat-toos (Gurke & Armstrong, 1997).

Previous tattoo removal techniques, such as sur-

gery, cryosurgery, and dermabrasion, have producedscarring and pigmentation responses, but now there ismore success with laser therapy. &dquo;Almost all tattooscan be lightened,&dquo; yet not all pigment ink can be re-moved adequately because some pigment inks, espe-cially green and yellow hues, respond individually tospecific lasers (Armstrong, Stuppy, Gabriel, & Ander-

son, 1997, p. 415). Additionally, the lack of knowledgeof the pigment ingredients by dermatologists preventsthe effective removal of tattoos.

Several types of lasers are being used for removal,yet some problems with laser therapy still exist, suchas (a) the lack of access to the proper treatment equip-ment because not all dermatologists or plastic sur-geons obtain the expensive, ever-changing laser ma-chines, (b) the procedure is not covered by insuranceand thus requires cash payments, and (c) the removalprocess can take from one to many treatments thatneed to be scheduled every 4 to 6 weeks until the de-sired effect is obtained. &dquo;Costs for a 2 inch x 2 inchtattoo range from $35 to $50; costs for removal of thesame size tattoo can range from $1,000 to $1,500&dquo;(Armstrong & Pace-Murphy, 1997, p. 182). Some cli-ents get impatient or discouraged and do not com-plete the whole series of treatments.

Body Piercing

Body piercing &dquo;involves the insertion of sharp im-plements, most often large-bore hollow needles (sizes12-16), to create an opening for decorative ornamentssuch as jewelry&dquo; (Greif & Hewitt, 1998, p. 28). Theactual procedure is relatively simple, performed byholding the desired skin site taut with some sort offorceps, puncturing the skin, and then threading thejewelry through the hole (Armstrong, Ekmark, &

Brooks, 1995). The usual body piercing sites includethe ears, eyebrows, nose, tongue, chin, and the navel.Nipples and genitalia are also pierced but will not bediscussed because they are more often seen in the 18to 30 year old. Table 2 provides detailed informationand instructions on the care of each traditional site of

body piercing.Although earlobes are perhaps the most traditional

and risk-free sites to accommodate jewelry, several

physicians, as well as many studio artists, have raisedserious concern over the use of &dquo;spring-loaded guns&dquo;to do the procedure (Koenig & Carnes, 1999; More,Seidel, & Bryan, 1999; Tweeten & Rickman, 1998). Theproblems are that many people wipe the gun cleanwith an antiseptic between piercing procedures andperform the procedure in unregulated cosmetic shops,shopping malls, and earring kiosks. The concerns ofthe Association of Professional Piercers regarding the



18

Table 2 Body Art Dos and Dont’s. Long-term satisfaction with body art increases with the amount of consideration given to its location, design, and the artist’s

skill. Most people who regret a tattoo do so because of its poor quality and their own quick decisions.. Customers must be informed about body art for their safety and to reduce infections, allergic reactions, and diseases.. Hepatitis B and C are easy to catch from an unclean shop or artist; recommend the hepatitis B vaccine to allwho want body art (before they get it!).

w Antibiotics are recommended for any person receiving body art who has a congenital or chronic illness (heart defects, diabetes,etc.)

~ For pain, take acetaminophen or ibuprofen. Do not take aspirin (it thins the blood and increases bleeding).. While healing, no one should ever touch the body art without washing their hands with soap first!



19

Table 2 Continued



20

guns are that the equipment tends to cause local trau-ma, are inaccurate, and cannot be effectively steril-ized, or even decontaminated, as a result of their sizeand complexity.

Piercing higher locations on the ear, above the earlobe and into the cartilage rim, should be defined asbody piercing rather than traditional ear lobe piercingbecause it requires more skin care. More infections arepresent at those sites (More et al., 1999). The auricularcartilage is less vascular, and when the piercing is com-bined with warm-weather sporting activities, presenceof hair, and the pressure from sleeping, a minor cel-lulitis can develop, later developing into an abscess.

Jewelry worn for body piercing should be specifi-cally designed for the sites and the procedure. Unfor-tunately, many adolescents tend to scrimp on thepiercing cost by purchasing poor quality earrings fortheir initial insertion, adding to the potential for lo-calized infections. Costume jewelry often containsnickel and brass, so allergic responses are frequentlyreported (McDonagh, Wright, Cork, & Gawkrodger,1992). Utmost care should be taken in the selection ofthe jewelry; recommended product ingredients in-

clude high-quality surgical stainless steel, niobium, ti-tanium, or 14-karat gold. Although the jewelry can bepurchased at the piercing studio, the ingredientsshould still be questioned. The bead ring and barbellconfigurations are the most popular and recommend-ed because they are easy to clean. After the piercing,the jewelry should be kept in place at all times to keepthe hole open because reinsertion can be difficult. Ifthe jewelry must be removed, piercers recommendsome sort of insertion taper such as a suture or 160-pound test fishing line lubricated with a small amountof antibiotic ointment for hole maintenance (NEHA,1999).

Care of the piercing site is essential. Postpiercingskin care should be considered a long-term commit-ment and initiated immediately upon leaving the stu-dio. Aftercare instructions are usually provided, butthe adolescent needs to heed the information. Healingtimes will depend on the type of piercing, location,and the amount of consistent skin care that is appliedto the area (see Table 2). Generally, facial piercingsheal in about 2 months, whereas the covered sites maytake at least 6 months or more. &dquo;Toughening up&dquo; ofthe hole can take up to a full year or longer.

If an infection occurs, the question arises of wheth-er the jewelry should be removed. Controversy sur-rounds keeping the jewelry in the piercing site to

&dquo;serve as a portal for drainage and healing, or if it isan obstacle&dquo; (Greif & Hewitt, 1998, p. 30). The jewelryremoval can allow for healing and closure of the epi-dermis but can also create abscess formation in deeperskin structures.

Although this should be considered on a per-casebasis, the Society of Professional Piercers and othersrecommend retaining the jewelry and initiating ag-

gressive skin care. In addition, the student may notwant to remove the jewelry. It is often noted the stu-dent will have another piercing done as the desire andintent for the piercing have not been removed.

Emphasize to students the importance of compari-son shopping for a reputable piercer, the avoidance ofany self-infliction of body piercing, and the timely na-ture of health provider consultation if a problem aris-es. Organisms can be introduced with poor techniqueand unclean equipment, as well as during postpiercingskin care. Frequent handling or &dquo;playing&dquo; with thejewelry can irritate the site. Risks surrounding self-in-fliction include nerve damage, poor locations, and&dquo;the entry of bacteria at the time of the piercing or inthe course of wound care&dquo; (Tweeten & Rickman, 1998,p. 735). Nerve damage associated with tongue pierc-ings can be demonstrated by a loss of taste, speechdifficulties, or permanent numbness. Pseudomonas andstaphylococus are the major organisms causing mostpiercing infections. Besides the hepatitis viruses (hep-atitis B and C) risk, specific health risks include en-docarditis from a nasal piercing and tetanus from aself-inflicted naval piercing (Koenig & Carnes, 1999;O’Malley et al., 1998). Dentists report halitosis,cracked teeth, impediments of speech, aspiration ofbarbells, and bleeding with tongue piercings (Price &

Lewis, 1997).Removal of a piercing site often involves simply

taking the jewelry out and allowing the hole to close.Closure times will vary, depending on their age, size,and location of the piercing. If the site has not ade-quately healed, it will close quickly when the jewelryis removed. Well-healed holes may take longer toclose, especially if the hole has been stretched. Thosesites should be watched because dirt and dead cellscan accumulate in the piercing (NEHA, 1999).

Scarification: Branding

Scarification is the general term for a form of bodyart that results in a scar. Branding is one of the specificmethods to accomplish it; cutting is the other methodthat can be used (NEHA, 1999). Although not exactlythe same as marking cattle, human branding still in-volves &dquo;burning a design into the skin&dquo; (NEHA, p.236). Although it is not a widespread procedure foradolescents and is considered an extreme or &dquo;hard-core&dquo; form of body art, it is being done and is fre-quently discussed in the media. The most frequent oc-currences of branding are among Black national fra-ternity members who undergo an initiation rite formembership. They proudly display their horseshoescars.

If a reputable studio artist performs the procedure,several thin strips of stainless steel are used to createthe desired simple design, then the strips are heated,often using a blowtorch. After the strip is pressed ontothe skin (a &dquo;strike&dquo;), resulting in a second- to third-



21

degree burn with the anticipated result of keloid scar-ring. Multiple strikes are necessary to complete the de-sign so &dquo;a simple brand could consist of 10 to 30strikes&dquo; (NEHA, 1999, p. 237). Obviously, this proce-dure is painful, yet some recipients report pain as partof the excitement of having it done. The cosmetic re-sult of the branding design (the depth and width ofthe scar) depends on the steady hand of a knowledge-able artist, the type of materials used for the branding,as well as the customer’s predisposition to keloids,which is often based on the amount of melanin in theskin (NEHA). Any roughening or scraping of the scarafter branding causes a further spread of the scar.

The first 2 months following the branding are im-portant for skin aftercare because of the resultingburn. Proper cleaning twice daily by gently washingwith soap and water helps keep the area free of dis-charge. Cleaning should be followed by a nonadher-ing dressing. Full healing of the skin will take up to ayear with the individual experiencing many skin colorchanges ranging from red, pink, to the end result of abrown, gray, or even a dark red brand.

Branding is not an experimental procedure for am-ateurs because the brand will have blobs of scar tissueand no desired design (NEHA, 1999). Unfortunately,there are adolescents who think that heated coat

hangers, paper clips, and even soldering irons im-mersed in boiling oil will produce the same results.Instead, these designs can produce uneven, enormousscars. Many of the above named implements used asbranding equipment contain ferrous metals, predis-posing recipients to allergic metallic responses. Thistype of body art should certainly be considered per-manent because removing scars surgically can resultin a different kind of scar. Lasers sometimes are usedfor removal, but the process is expensive, and the re-sponse is individual and unpredictable.

IMPLICATIONS FOR SCHOOL NURSING PRACTICE

School nurses can take several steps to assist stu-dents who are considering or have undergone bodyart procedures. First, take some time for a self-exami-nation of your attitudes regarding the various formsof body art and the students who have them. Oneform of body art may not be a problem for you, where-as others are (e.g., &dquo;I don’t mind a tattoo, but I reallydon’t like the pierced tongue&dquo;). Negative attitudes canimpact client care, therefore awareness of your feel-ings can assist both formal and informal communi-cation between you and the student. Nonjudgmentalcommunication can increase the responsiveness of thestudent to the health teaching or treatments beingpromoted. You may also wonder, &dquo;Why are they doingbody art?&dquo; Multiple studies on tattooing among wom-en, adolescents, college students, and military recruits,show similar reasons for desiring tattoos as &dquo;just want-ed one, self-expression, and to feel unique&dquo;, with the

purpose of &dquo;to be myself, I don’t need to impress any-one anymore&dquo; (Armstrong, 1991; Armstrong & Mc-

Connell, 1994b; Greif et al., 1999; Armstrong et al.,2000; Armstrong & Pace-Murphy, 1997, p. 185)

Next, explore the existing regulations in your com-munities, county, and state. Look at what is presentnow, what is needed, and what should be planned forthe future. Talk to students with body art about theprocedure, the studios, and the environment wherethey had their procedures done. Visit the studio as aninterested observer. Consider getting involved in yourcommunity’s efforts to create new or enforce existingbody art regulations. Unregulated, unlicensed artistsmay or may not be practicing hygienic body art pro-cedures.

Recently, the NEHA took a proactive stand and be-came the first public health organization in the nationto address body art issues by developing a Compre-hensive Model Body Art Code. (See the appendix forinformation on how to obtain a copy of it.) The re-sulting code is important because it is intended as aprofessional advisory document with recommenda-tions for health officials wishing to regulate the bodyart industry in their respective jurisdictions. It estab-lishes public health criteria and recommendations foroperators to safely provide body art services to thegeneral public (Armstrong & Fell, 2000). Several stateshave used the NEHA Code when implementing newbody art regulations. The school nurse armed with thisinformation could go to local or state officials with

nationally approved standards as a foundation of ref-erence to compare with existing regulations.

In the practice setting, key issues faced by schoolnurses include what to report, who to report to, andconfidentiality concerns. To ensure that artists practic-ing unsafe body art procedures do not continue to ex-pose clients to infection and disease, violations shouldbe reported. Contact local and or state health depart-ment personnel for reporting procedures. Confidenti-ality issues with students will come up when you be-gin reporting artists, however. Will students tell youwhere they received their body art if they know youmight report the artists? Should you contact the stu-dent’s parents or guardians if you are reporting thebody art artist? These are some of the issues the schoolnurses must consider.

Perform a risk assessment on students with new

body art. Did the artist wash his or her hands and weargloves? Were new needles used or removed from au-toclaved packages? If the student was shaved, was therazor new? Was the tattoo ink freshly prepared for thestudent and discarded after use? Did the student re-ceive aftercare instructions? What were they? Shouldthe nurse contact parents or guardians if a student hasreceived body art from an artist who used unsafe pro-cedures ? The student may have been exposed to hep-atitis B or C. The nurse will need to discuss the hep-atitis risk and may recommend the hepatitis B vac-



22

cine. Does the state require parental consent for thehepatitis B vaccine? Should parents or guardian becontacted if the body art becomes infected and re-quires medical attention, or can the nurse do a

straight referral?Last, and most important, design short programs

about body art safety. The purpose of health educa-tion should be to &dquo;emphasize potential risks, pose def-inite questions and actions to minimize the risks, andencourage reconsideration or postponement of bodyart decisions&dquo; (Armstrong & McConnell, 1994a, p.27). In addition, brochures and a health educationvideo are available. (See the appendix for informa-tion about these items.) Encourage adolescents tothink of themselves as a &dquo;growing and changing per-son&dquo; rather than saying &dquo;no&dquo; and using scare tactics.Include the teachers and staff, but also consider or-ganizing separate sessions for the students to discussthe issues. All of the personnel in the school interactwith students in various ways, and separate peopleaddressing the same concerns can have an impact onthe student.

SUMMARY

Overall, the body art industry remains an artist-consumer-regulated business in our present-day, con-sumer-driven society with &dquo;no money-back guaran-tees, no government testing, no samples associatedwith the procedure, limited regulations and controls,and still there is potential for blood-borne disease&dquo;

(Armstrong, 1991, p. 220). School nurses are in a pow-erful and influential position to provide students withaccurate information to assist them in the decision-

making process. They also have an important role ineducating students about the care of body art to pre-vent infections and other related complications. Fi-

nally, school nurses should take advantage of oppor-tunities to institute body art regulations in their com-munities or state.

ACKNOWLEDGMENTS

The authors gratefully acknowledge Julie Magness,program manager, Texas Department of Health, Drugand Medical Devices for assistance in the developmentof this article and Janet C. Bundy, RN, CIC, PHc forher thoughtful review of the manuscript.

REFERENCES

Armstrong, M. L., Ekmark, E., & Brooks, B. (1995). Body pierc-ing: Promoting informed decision-making. Journal of SchoolNursing, 11(2), 20-25.

Armstrong, M. L., & Fell, P. R. (2000). Body art code: The con-cerns and the NEHA Body Art Model Code. Journal of Envi-ronmental Health, 62, 20-25.

Armstrong, M. L., & McConnell, C. (1994a). Promoting in-formed decision-making about tattooing for adolescents.

Journal of School Nursing, 10(2), 27-30.

Armstrong, M. L., & McConnell, C. (1994b). Tattooing in ado-lescents: More common than you think: The phenomenonand risks. Journal of School Nursing, 10(1), 22-29.

Armstrong, M. L., & Pace-Murphy, K. (1997). Tattooing: Anotherrisk-behavior in adolescents warranting national healthteaching. Applied Nursing Research, 10, 181-189.

Armstrong, M. L., Pace-Murphy, K., Sallee, A. S., & Watson, M.G. (2000). Tattooed army soldiers: Examining the incidence,behavior, and risk. Military Medicine, 165, 135-141.

Armstrong, M. L., Stuppy, D. J., Gabriel, D. C., & Anderson, R.R. (1997). Motivation for tattoo removal. Archives in Derma-tology, 132, 412-416.

Anderson, R. R. (1992). Tattooing should be regulated. New Eng-land Journal of Medicine, 326, 207.

Armstrong, M. L. (1991). Career-oriented women with tattoos.Image: Journal of Nursing Scholarship, 23, 215-220.

British Medical Association. (1990). Code of practice for safe useand disposal of sharps. London: Chamelion Press.

Cetta, F., Graham, L. C., Lichtenberg, R. C., & Warnes, C. A.(1999). Piercing and tattooing in patients with congenitalheart disease: Patient and physician perspectives. Journal ofAdolescent Health, 24, 160-162.

Doll, B. S. (1988). Tattooing in prison and HIV. Lancet, 1, 66-67.

Duke, D., Urioste, S. S., Dover, J. S., & Anderson, R. R. (1998). Areaction to a red lip cosmetic tattoo. Journal of the AmericanAcademy of Dermatology, 39, 488-490.

Elster, A. D., Link, K. M., & Carr, J. J. (1994). Patient screeningprior to MR imaging: A practical approach synthesized fromprotocols at 15 U.S. Medical centers. American Journal of Ra-diology, 162, 195-199.

Greif, J., & Hewitt, W. (1998). The living canvas. ADVANCE forNurse Practitioners, 12, 26-31, 82.

Greif, J., Hewitt, W., & Armstrong, M. L. (1999). Tattooing andbody piercing: Body art practices among college students.Clinical Nursing Research, 8, 368-385.

Gurke, B., & Armstrong, M. L. (1997). D-TAG: Erasing the tag ofgang membership. Journal of School Nursing, 13(2), 13-17.

Koenig, L. M., & Carnes, M. (1999). Body piercing: Medical con-cerns with cutting-edge fashion. Journal of General InternalMedicine, 14, 379-385.

Kreidstin, M. L., Giguere, D., & Freiberg, A. (1997). MRI inter-action with tattoo pigments: Case report, pathophysiology,and management. Plastic and Reconstructive Surgery, 99, 1717-1720.

Long, G. E., & Rickman, L. S. (1994). Infectious complicationsof tattoos. Clinical Infectious Diseases, 18, 610-619.

McDonagh, A. J. G., Wright, A. L., Cork, M. J., & Gawkrodger,D. J. (1992). Nickel sensitivity: The influence of ear piercingand atopy. British Journal of Dermatology, 126, 16-18.

More, D. R., Seide L. J. S., & Bryan, P. A. (1999). Ear-piercingtechniques as a cause of auricular chondritis. Pediatric Emer-gency Care, 15, 189-192.

National Environmental Health Association. (1999). Body art: Acomprehensive guidebook and model code. Denver, CO: Author.

O’Malley, C. D., Smith, N., Braun, R., & Prevots, D. R. (1998).Tetanus associated with body piercing. Clinical Infectious Dis-eases, 27, 1343-1344.

Price, S. S., & Lewis, M. W. (1997). Body piercing involving oralsites. Journal of the American Dental Association, 128, 1017-1020.



23

Pugatch, D., Mileno, M., & Rich, J. D. (1998). Possible transmis-sion of Human Immunodeficiency Virus Type I from bodypiercing. Clinical Infectious Diseases, 26, 767-768.

Schnirring, L. (1999). Body piercing and sports: An opening fortrouble? Physician and Sportsmedicine, 27, 27-28, 33.

Shea, J. (1998, July 25). It’s important for people to know thattattooing and body piercing opens people to the transmissionof dangerous viruses such as hepatitis, B, hepatitis C, and HIV.American Reporter (Oklahoma City ). Retrieved June, 1999,from the World Wide Web: http://www.american-reporter.com

Shimokura, G. H., & Gully, P. R. (1995). Risk of hepatitis C virusinfection from tattooing and other skin piercing services. Ca-nadian Journal of Infectious Disease, 6, 235-238.

Sperry, K. (1991). Tattoos and tattooing part I: History and meth-odology. American Journal of Forensic Medicine and Pathology,124, 313-319.

Tope, W. D. (1995). State and territorial regulations of tattooingin the United States. Journal of the American Academy of Der-matology, 32, 791-799.

Tweeten, S. S. M., & Rickman, L. S. (1998). Infectious compli-cations of body piercing. Clinical Infectious Diseases, 26, 735-740.

APPENDIX

The NEHA Body Art Model Code and Guidelinescan be obtained by contacting NEHA at (303) 756-9090, E-mail: [email protected]; or http://www.neha.org.

Commercial brochures available on body art in-

clude the following:

~ Thinking about tattooing or body piercing (715633A).For information: Attn: Corinna Wadleigh, Director,Educational Resources, Channing L. Bete Co., Inc.Tel. (800) 628-7733.

. Several brochures are available from ETR Associates:

Incredible Body Art Facts; Incredible Tattoo Facts; BodyArt: Talking with Your Teen; Body Art: A Self Test. Is Itfor You?; Taking Care o f Body Piercings; and GettingWhat You Want From Body ART. Available from ETRAssociates. Tel. (800) 321-4407, fax (800) 435-8433,Internet: www.etr.org.

. Tattoos: A guide for safety and body piercing: A guide tosafety. Available from W. R. Spence MD, HealthEDCO, Waco, TX 76702-1207. Tel. (800) 299-3366;Internet: www.healthedco.com

The following health education video provides in-formation on tattooing: A tattoo? ... You. Teens talkingto teens. Discusses risks, the procedure, and tattoo re-moval. Running time: 8 minutes, 40 seconds. Cost:$55 (includes shipping and handling). Texas Tech Uni-versity Health Sciences Center School of Nursing,Room 2B164, 3601 4th street, Lubbock, TX 79430. Tel.(806) 743-2002; fax (806) 743-1622.



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