Tattoos and piercings were once relegated to specific cultures and societal types but are be­coming increasingly common across all ages and genders throughout the United States. “For emergency physicians (EPs), tattoos and piercings have become important non-verbal clues about someone’s lifestyle,” says Michael S. Urdang, MD, BSc, MBBS, MRCS. “In addition, these body modifications have been identified as the cause of an ED visit more often in recent years.”

Considering the large scope of tattoos and pierc­ings among ED patients, EPs must recognize and understand the medical complications that may arise as a result of these body modifications. A deeper understanding of the psychological associ­ations of tattooing and piercings is also important. In addition, EPs should recognize the relevance of body modifications to the current chief complaint when patients present to EDs.

In the November 2011 Western Journal of Emergency Medicine, Dr. Urdang and colleagues published a review in which the most common forms of tat­toos and piercings were elucidated. The review also described how these body modifications may have affected the physical and psychological health of patients undergoing treatment. Potential pitfalls in treating complications associated with tattoos and piercings were also described in the review.

Increasing Prevalence of Tattoos & Piercings

Recent surveys have shown that there has been a significant increase in the prevalence in tattoos within the U.S. In 2006, a North American survey of adults aged 18 to 50 found that 24% had tat­toos and 14% had body piercings (excluding the ear). Those who were tattooed were more likely to be less educated, use recreational drugs more fre­quently, and less likely to show any religious affili­ation. At about the same time, 2% of Americans reported having piercings (not including the ear lobe). Studies suggest that people who get pierc­ings are more likely to partake in risky activities (eg, drug taking and sexual promiscuity) and have a higher risk of being incarcerated.

Examining the Relevance to Emergency Physicians

“Tattoos and piercings are relevant to EPs in many ways,” says Dr. Urdang (Table 1). “First, they pres­ent a window to the lifestyle and life experiences of the patient being treated. Furthermore, tattoo­ing can camouflage intravenous drug abuse and other dermatologic diseases. Many questions rel­evant to the patient’s history can be answered by a review of their tattoos. While making interpretations is not always simple, rel­evant information is often within reach of observant EPs.” Most complications from tattoos are related to infections that can be traced back to tattoos be­ing given via non-sterile techniques. Failure to recognize tattoos as the source of complications can lead to incorrect therapy.

Piercings can have an effect on how diagnostics and other proce­dures are utilized in the ED. They can also lead to several types of complications that can impact how EPs treat these patients (Table 2). “Jewelry is primarily body-site specific and made from metal,” Dr. Urdang explains. “When various metals that are used in jewelry con­tain nickel, there is a potential for complications, including infections, traumatic insertions, rejection of foreign bodies, migration, and/or embedding.” Complications of piercings are more common than those of tattoos, with studies demonstrating com­plication rates as high as 9%.

Considering Psychological Associations with Tattoos and Piercings

Data suggest that EPs should recognize that tat­toos and piercings have been linked to illnesses and suicidal behavior. Tattooing has been correlated with the perception of decreased mental health. Tattooing and body piercing together have been linked to an increased likelihood of “sensation-seeking” behavior. Abusive backgrounds, mental illnesses, and suicidal ideation are more frequent among people with body modifications like tat­toos and piercings than in those without them. “While these associations cannot be generalized to everyone with tattoos and piercings, they can be of assistance when diagnosing and treating pa­tients in the ED,” says Dr. Urdang.

Studies have shown that about half of people with tattoos regret getting them within 12 to 14 years and wish for tattoo removal. “Tattoos may cause imme­diate or delayed hazards to health and aren’t always easy to remove,” says Dr. Urdang. “Fortunately, non-profit organi­zations and other businesses have emerged to provide tattoo removal. Some even clear away tattoos for for­mer gang members who want them removed. Several removal methods are available, so it’s important that EPs re­search the different treatment approaches to see which strategies are appropriate, de­pending on the patient’s situation. Arming EPs with knowledge about tattoos and pierc­ings can forge more functional doctor–patient re­lationships in the ED. It can also assist them as they obtain critical historical data and informa­tion about their patients. Ideally, this information will enable EPs to provide better treatment and referral for this growing patient population.”


Urdang M, Mallek JT, Mallon WK. Tattoos and piercings: a review for the emergency physician. Western J Emerg Med. 2011;12:393-398. Available at:

Armstrong ML, Roberts AE, Koch JR, et al. Investigating the removal of body piercings. Clin Nurs Res. 2007;16:103-118.

Lick SD, Edozie SN, Woodside KJ, et al. Streptococcus viridans endocarditis from tongue piercing. J Emerg Med. 2005;29:57-59.

Meltzer DI. Complications of body piercing. Am Fam Physician. 2005;72:2029-2034.

Stuppy DJ, Armstrong ML, Casals-Ariet C. Attitudes of health care providers and students toward tattooed people. J Adv Nurs. 1998;27:1165-1170.

Hicinbothem J, Gonsalves S, Lester D. Body modification and suicidal behavior. Death Stud. 2006;30:351-363.

Burris K, Kim K. Tattoo removal. Clin Dermatol. 2007;25:388-392.

Stirn A. Trauma and tattoo-piercing, tattooing and related forms of body modification between self-care and self-destruction of traumatized individuals. Psychotraumatologie. 2002;2:45.