Piercing or breakage of the skin occurs with electrolysis, ear piercing, tattooing, acupuncture, body piercing, branding and other scarification methods.  When a needle, razor or other similar instrument breaks a person’s skin, blood, serum or small fragments of tissue will adhere to the needle or instrument used.  These can then be directly transferred to the bloodstream of another person, or could contaminate materials or other pieces of equipment.  In this way, infection can be transmitted.  This includes viral infections, e.g. Hepatitis B, Hepatitis C and HIV (Human Immunodeficiency Virus).

There is a body of legal opinion that deep body piercing borders on a surgical operation, yet the practice of clinical surgery without medical qualifications is a criminal offence.  Poorly trained body piercers may have insufficient knowledge of human anatomy and ‘clean’ techniques to perform piercing safely.  They may put themselves and their customers at serious risk.

Legislation

Premises carrying out electrolysis, ear piercing, tattooing and acupuncture may need to be registered with the Local Authority under the Local Government (Miscellaneous Provisions) Act 1982.  Some authorities have also made byelaws under the 1982 Act relating to cleanliness of premises, practitioners and assistants and cleansing and sterilisation of equipment.  Body piercing is not currently subject to the registration requirements of the 1982 Act, but piercing practitioners must also comply with relevant health and safety legislation, e.g. s.2 and s.3 of the Health and Safety at Work etc. Act 1974.

Age and consent issues

The Tattooing of Minors Act (1969) prohibits the tattooing of anyone in Great Britain under the age of 18 years, but there is no such statutory age limit for ear piercing or cosmetic body piercing.  Under the Sexual Offences Act (1956), girls and boys under the age of 16 cannot legally give consent to intimate sexual contact under any circumstances, so piercing of nipples and genitalia (for girls) or genitalia (for boys) could be regarded as an assault offence.  The law allows children under the age of 16 to consent to other piercings provided they are sufficiently mature to understand the nature of the request.

This kind of assessment is clearly a subjective matter for the piercer involved.  Body piercers are advised to adopt reasonable age restrictions to avoid parental conflict and legal complications and to enhance their reputation for high standards.  The client should also be provided with sufficient information to allow them to proceed in an informed way and without pressure.  Sometimes, the greatest pressure to get pierced may come from friends or relatives.  If piercers are willing to treat minors, the presence of a parent or guardian during any such procedure is recommended.

Use of Anaesthetics

It is illegal for piercers to administer local anaesthetic injections or Emla cream unless medically qualified under the Medicines Act 1968. Some topical anaesthetics can readily cause skin damage if misused.

The use of Lignocaine-based cream/spray and Ametop gel or administration by a body piercer is not in itself an offence, therefore Xylocaine (which contains Lignocaine) can therefore legally be used, where appropriate, by the tattooist/body piercer.  Before proceeding, the piercer must ensure that they ask the client to complete a contra-indication medical questionnaire.  If clients answer ‘yes’ to any of the questions, they should be advised to seek medical advice.

The use of Xylocaine spray for tongue piercing (or similar) is not appropriate because the spray form is not licensed for use on the tongue.

If Xylocaine is to be used at all for oral procedures then the 4% topical suspension is licensed by the manufacturer (Astra-Zeneca) to provide anaesthesia of oral mucous membranes.

Control of Substances Hazardous to Health Regulations 1999

Assessments will need to be carried out under the above.  Most reputable suppliers provide basic information, including storage details and a hazard rating with the product.  Hazard ratings will indicate whether a substance is toxic or very toxic, flammable, harmful or irritant, corrosive, etc.  For example: 70% alcohol is flammable; Ethyl chloride spray, a pharmacy issue drug, is used in dental surgery, chiropody, ear piercing and other minor surgical procedures.  The product is volatile, highly flammable and subject to a COSHH assessment prior to its appropriate use.  It must be carefully stored, monitored during storage and disposed of as special waste.

SKIN PIERCING: BYELAWS

The following standards provide a useful guide for all skin piercers (including body piercers) that will help you to comply with s.2 and s.3 of the Health and Safety at Work etc. Act. 1974).  They may form part of local bylaws and any registration certificate and a copy of the byelaws should be displayed.

Skin Piercing Rooms:

• all internal surfaces to be clean and in good repair
• floors in tattooists to be smooth and impervious
• treatment area in tattooists and acupuncturists to be used solely for giving treatment
• furniture and fittings should be kept clean and in good repair
• tables, couches and seats used by clients in the treatment area, and surfaces for needles, instruments, materials and equipment immediately prior to use:-

to have smooth, impervious surfaces

to be disinfected:-

*between clients (tattooists)

*at least daily (acupuncturists)

*regularly (ear piercing/electrolysis)

• where tables or couches are used, a new disposable sheet to be used for each client
• prominent ‘No Smoking’ signs.

Waste Disposal:

disused needles to be put into covered and leakproof sharps’ boxes and safely disposed of at suitable intervals

all other waste to be put into suitable covered containers, emptied daily and disposed of safely

(Waste from skin piercing undertakings now comes within the definition of clinical waste and companies involved in waste disposal will usually provide approved plastic incinerator bins for the collection of dressings, sharps etc.)

Cleansing/Sterilisation

A)  Instruments, materials and equipment

Operator:   

• protective clothing, coverings, cloths etc.
• clean, good repair, sterile (as far as is appropriate)
• needle, instrument, equipment to be sterile until used
• dyes to be bacteriologically clean and inert (tattooists)
• dye containers to be either disposable (at each session of treatment) or sterilised before re-use (tattooists)

Proprietor:

• facilities and equipment to be provided for sterilisation (unless disposable/pre-sterilised) and cleansing
• sufficient gas/electrical points to be provided
• adequate and constant hot and cold water supply
• adequate storage for equipment provided

B)  Cleanliness of Operators

Operators:

• to ensure they have clean hands, short nails (tattooists and acupuncturists), clean clothing (ear piercing/electrolysis); clean and washable clothing or disposable covering used once only (tattooists and acupuncturists); open wounds covered by an impermeable dressing, observe prohibition on smoking/eating/ drinking in the area

Proprietor:

• to provide suitable and sufficient washing facilities

SKIN PIERCING: SAFE SYSTEMS OF WORK/BEST PRACTICE:

Notices/Records:

Record keeping protects the interests of both piercer and client.  The client, because technical details of their treatment are noted, so the treatment and any follow-up care can then be tailored in the knowledge of all relevant details.  For the piercer, the identification of any allergies or health problems that may affect treatment is essential to avoid complications during or after the procedure.  Declaration and proof of age should be a fundamental part of this process.  Records should be kept for a minimum of one year, and preferably for two years.  Records should include:

• date of procedure;

• the client’s name, contact address and their telephone number;
• details of the procedure carried out;
• a record of the type of body jewellery used, if applicable.  If the piercer did not supply jewellery, then details of the supplying outlet should be obtained from the client;
• a medical history is important to establish any relevant medical conditions.  A basic health declaration can be presented in tick-box format and should include any history of:

Heart disease (including heart ‘murmurs’) or high blood pressure

Medication

Pregnancy/breast feeding

Blood-borne viruses such as HIV, Hepatitis B and C,

Low blood pressure (this can make an individual prone to fainting attacks)

Medical condition that may cause a tendency to haemorrhage, e.g. leukaemia

Epilepsy in any form

Diabetes

Impetigo, a skin infection often caused by the bacterium Streptococcus

Skin conditions such as eczema, psoriasis and warts

Allergies, particularly to metals, adhesive dressings or topical creams

• if there is a history of relevant medical conditions, the client should be advised to see their GP for advice on suitability for piercing;
• some indication as to whether the client is under the influence of drugs or alcohol, or have a history of drug/alcohol problems.  If so, clients should be advised not to undergo tattooing or piercing; and
• discussion with piercers has highlighted particular problems with false age declarations prior to treatment.  Underage clients may also give false names as well as a false age.  Encouraging piercers to note down additional client information (eg characteristic birthmarks, other piercings) may help them to locate their records, and to confirm identities in any follow-up procedures.

Training of piercers

Many accredited training courses are provided by colleges, equipment suppliers/manufacturers in respect of the activities of electrolysis, acupuncture and ear piercing.  There are, however, currently no approved training courses available for body piercing or tattooing, although a number of commercially run courses are available.  It is recommended that basic first aid training, and dealing with body fluid spillages, needle stick injuries be provided as part of any body piercing training course.

Infection control measures

Preventing the transmission of infection is essential in skin piercing practice, as there have been outbreaks of hepatitis B infection associated with tattooing and acupuncture in the past.  (For more detailed advice you should consult the Health and Safety Team or the Consultant in Communicable Disease Control or the local community infection control team):

Immunisation for body piercers and tattooists

Immunisation against hepatitis B is strongly recommended for piercers and tattooists and for staff who may be involved in cleaning skin penetration instruments and equipment.  There is still no vaccine available against HIV or hepatitis C.

Anyone handling sharps is also advised to be up to date with their tetanus immunisation.

Immunisation can be obtained from the piercer’s/tattooist’s GP.

Skin piercers should keep copies of their antibody results following immunisation for inspection.

Needle Stick Injuries

If a needle stick injury takes place with a needle that has been used on a client’s blood, tattooists/piercer’s should seek medical advice as soon as possible.

Personal hygiene

Hand washing is an important procedure for preventing the spread of infection.  This has been shown repeatedly in the hospital environment.  Hand washing is best performed using liquid soap, preferably one with an antiseptic action and running water in a purpose-designed basin, with effective drainage.  Water should preferably be supplied hot and cold via a lever-operated mixer tap, and hands are best dried with disposable towels, not multi-use cloth towels.

Hand washing is particularly important:

• before and after tattooing or skin piercing procedures;
• whenever hands become accidentally contaminated with blood, body fluids or secretions;
• after removing protective gloves;
• after visiting the toilet;
• before handling food and drinks;
• smoking should not be allowed during skin piercing procedures or treatment, as there is the risk of transferring bacteria from the piercer’s mouth via fingers to the client.  Staff should wash their hands after smoking.  Suitable detergents, disinfectants and antiseptics can be used to reduce the risk of infection; and
• the piercer/tattooist should cover any cuts or grazes they have prior to starting treatment.  Their nails should be clean and short and eating and drinking should be avoided in the clean treatment area.

Personal Protective Clothing

It is recommended that surgical style gloves be used to protect the piercer during contact with bodily fluids and tissues.  This barrier also protects the client from any micro- organisms harboured on the piercer’s hands but should NOT be regarded by a piercer as a substitute for good hand washing.

• disposable latex or vinyl gloves should be worn during tattooing and piercing procedures and must be disposed of between clients.  Some people develop latex allergies with prolonged use, and many prefer vinyl-based materials;
• gloves should always be changed if punctured at any time during a procedure;
• hands should always be washed after glove removal;
• domestic style gloves should only be used for equipment cleaning;
• clean, washable clothes are suitable for use by the piercer or tattooist, but if heavy soiling is anticipated then a disposable plastic apron should be worn and should be disposed of between clients,
• if heavy bleeding is anticipated, additional protective equipment should be considered by the piercer to protect mucosal surfaces from blood splash, e.g. safety spectacles, face mask; and
• re-usable cotton towels should NOT be used as clothing protection.  They may harbour and transmit blood-borne infection even after hot machine washing.

Cleaning and disinfection

Important Definitions:

Cleaning - a process that physically removes contamination but does not necessarily destroy micro-organisms.

Disinfection - reduces the number of viable micro-organisms but it may not necessarily inactivate some bacteria, fungi, viruses and spores.

Sterilisation - renders an object free from viable micro-organisms, including bacterial spores.

Cleaning:

Thorough cleaning is needed before disinfection/sterilisation.  Detergents may assist cleaning and must be compatible with the materials from which the equipment and work surfaces are made.

Scrubbing should be avoided as this can create aerosols, which can spread infectious agents from contaminated equipment.  Ultrasonic cleaning is more consistent than manual cleaning and reduces aerosol formation.  It should be noted that a product might be suitable for some areas but not others.  In particular, many products may be designed for either skin or environmental application, but not both, e.g. bleach solution (1000ppm) can be used effectively on hard work surfaces but might be harmful to skin or metal instruments.

Washing up type gloves and eye protection should be worn when manually washing instruments.

Surfaces

Disinfection of surfaces may be achieved using bleach containing minimum 1000ppm available chlorine or purpose-designed disinfection products.

Skin

Of the preparations available, 70% alcohol (ethanol or isopropanol) is considered the most effective skin disinfectant and the least likely to cause harm.

Instruments

Used instruments should be cleaned thoroughly to remove all debris and body fluids, first in cool water (below 35oC) and then in warm water.

• Piercers should use sterile single use tubes, grips and/or tips; or alternatively, if instruments must be re-used, the following guidance should be applied;
• Use a hospital sterile services department for sterilisation;
• Bench top steam sterilisers may be used – but they must be suitable for the equipment that the user intends to process.  Items that are packaged, hollow or tubular should usually be sterilised in a steriliser that has forced air removal (e.g. pre-sterilisation vacuum stage) and which has been validated for the intended items.  For packaged items, the steriliser must have an effective post- sterilisation drying stage.  The suitability of a particular steriliser for a particular load needs to be verified to ensure sterilisation
• where vacuum steam sterilisers are used, ensure prior cleaning of equipment by ultrasonic cleaner, brushing with narrow brushes and flushing through with water; and
• the use of a traditional, non-vacuum steam steriliser, with prior cleaning of equipment by ultrasonic cleaner, brushing with narrow brushes and flushing through with water.
• hot air ovens, glass bead sterilisers, water boilers and UV light boxes are not reliable methods of sterilisation and must not be used.
• sterilised items once unwrapped or removed from the steriliser should be used immediately.  If this is not practicable, after sterilisation, they may be stored in a clean, dry, disinfected air-tight container

Use of Sterilisation indicators

Sterilisation indicators change colour when the specified time and temperature have been achieved for sterilisation.  Only emulating indicators conforming to ISO 11140 part 1 - Sterilisation of health care products – Chemical indicators (Class 6 – Emulating indicators) will show, when placed in the load, whether sterilising conditions have been attained at that point.

Autoclave tape, or the indicators printed on the outside of a sterilisation bag or pouch are only intended to show exposure to steam, i.e. to distinguish items that have been processed from those that have not been processed.  They do not show that sterilising conditions have been met within a packaged item.  The use of an inappropriate indicator can give dangerously misleading results.

Sterilisation indicators are a quality control measure and are not a substitute for routine periodic testing, validation and correct maintenance of a steriliser.  It is essential that sterilisers are well maintained and operate at the correct temperature.

Aftercare advice

Examples of recognised problems following piercing and tattooing include:

Jewellery embedding - where part or all of the inserted item sinks beneath the skin surface after piercing.  This commonly happens after inappropriate use of ear-piercing guns on other body parts, e.g. navels.

Allergies to jewellery – this is often the result of nickel allergy, poor gold plating or the use of 9 carat gold materials.  Most piercers now use low nickel surgical grade steel to avoid this problem.  Eighteen carat gold is less likely to cause allergic responses than 9 carat, but is much softer than steel and so is avoided by many piercers.

Migration of jewellery – can happen to any pierced area, especially if inserted jewellery is too thin or is agitated before healing.  This can also be a problem with implanted (subcutaneous) items used in scarification and piercing procedures, and result in jewellery migrating through or under the skin, away from the original point of insertion.

Scarring – when not a planned part of the treatment, this is sometimes the result of poor jewellery insertion, jewellery migration or of infection and poor healing generally.

Severe localised swelling – can happen anywhere following tattooing or piercing, but particularly dangerous with oral piercing (proximity to airway), e.g. the tongue may swell to 3 times its normal thickness after piercing and this must be accommodated by the correct choice of jewellery.

Localised infections – usually caused by opportunistic skin bacteria, e.g. Staphylococcus, Streptococcus and Propionibacterium spp.  Usually subsides with good aftercare, but may become systemic.

Septicaemia – a serious systemic infection, i.e. affecting the whole body.  May be life threatening and requires immediate medical intervention in the form of antibiotics.

Bleeding – Must be expected for most piercing and sometimes occurs following tattooing, but may become excessive.  High-risk areas include male genital piercing (Prince Albert / ampallang) and tongue piercing.  Lips (labret) may also bleed profusely.  These areas have rich blood supplies that may lead to haemorrhaging after piercing.

After care advice should always be given to clients and should include personal hygiene, expected healing time, potential problems and when to seek medical advice.

Studies have shown that verbal aftercare advice provided after treatment is rarely heeded.  The client is often eager to leave the skin piercer’s premises, may be suffering discomfort or may simply be excited by the results of the treatment, and this can limit their attention.  It may therefore be prudent, for the skin piercer to offer advice before the procedure is carried out and while they have the client’s full attention; but then reinforce this during and after the procedure.  This can logically be done immediately after the questionnaire is completed and would include basic instructions to minimise healing times and reduce the risk of acquiring infection at the treatment site.

• A good standard of personal hygiene will generally assist in reducing the risk of wound infection.  It is considered preferable to leave the pierced area completely dry.  In view of this, advice should be given to avoid submersion or direct handling of the newly pierced site for at least 4 days after the initial piercing.  This will allow drying of the wound and will greatly reduce the chance of wound infection;
• Cleaning, and the use of skin disinfectant chemical can result in damage to delicate scar tissue and extended healing time and should therefore be avoided; and
• For body piercing, expected (complete) healing times are difficult to predict because individuals’ healing abilities vary, but a client should be told what to expect.  The healing time is the time required for the jewellery ‘tunnel’ to become dry and healed after the initial tissue damage.  General guidelines are scarce in this area, but those from the US Association of Professional Piercers are:

Ear lobe, eyebrow and nasal septum: 6 – 8 weeks

Ear (cartilaginous region) and nostril: 2 months to 1 year

Tongue: 4 to 6 weeks

Lips and cheeks: 6 to 12 weeks

Genital (female and male) including inner labia, clitoral hood: 4 to 12 weeks

Nipple, scrotum, outer labia: 2 to 6 months

Navel, ampallang (a transverse penile piercing): 4 months to 1 year

NB  Both piercer and client should treat excessive bleeding after body piercing seriously.  In the first instance, firm pressure should be applied to the area with clean dressings, e.g. gauze.  Ice on a pierced tongue may also reduce swelling and bleeding.  If bleeding persists in any area, but in particular after tongue piercing, medical help should be sought from the nearest accident and emergency department.  Clients should be encouraged to return to their piercer as a matter of routine for follow up care within two weeks to see if anything abnormal around the pierced site.

CHECKLIST - SKIN PIERCING

Do you carry out any skin piercing?

YES /NO

If you carry out ear piercing, acupuncture, electrolysis or tattooing, are you registered with the local authority?

YES /NO

Do you comply with the provisions of any relevant skin piercing byelaws?

YES /NO

Do you follow recommended methods of working forskin piercing or body piercing?

YES /NO

Are you, or your staff, experienced/trained/ qualifiedin skin piercing techniques and practices?

YES /NO

REFERENCES/FURTHER DETAILS

1. Byelaws relating to ear piercing and electrolysis, tattooing and acupuncture (NBBC).
2. ‘Blood-borne viruses in the workplace: guidance for employers and employees’. HSE Books  www.hse.gov.uk/pubns/indg342.pdf
3. Guidelines for control of infection in special treatments (tattooing, body piercing and acupuncture)’, by The Working Party of London Consultants in Communicable Diseases Control and Community Infection Control Nurses www.krha.nhs.uk/publication/guidelines.pdf.
4. A guide to hygienic skin piercing - Dr. Noah (P.H.L.S, C.D.S.C., 61 Colindale Avenue, London, NW9 5EQ
5. ‘Body Art, cosmetic therapies and other special treatments’  Chartered Institute of Environmental Health. (ISBN 1-902423-80-1)   (e-mail: shop@cieh.net)
6. ‘Immunisation against infectious disease’ 1996 HMSO, ISBN 0-11-321815-X (Department of Health)

return_to_top