| As in Amsterdam [1], the impetus for UK guidelines for
hygienic tattooing came from an outbreak of hepatitis B caused in 1978 by
a tattooist. The outbreak resulted in 30 primary and three secondary cases
[2]. Guidelines for hygienic tattooing followed soon after, and were taken
up, fairly enthusiastically on the whole, by the tattooists. These were
expanded in 1982 to include acupuncture, ear-piercing and hair electrolysis.
Laws to control the hygiene of these practitioners were introduced at the
same time {Local Government Miscellaneous Provisions Act 1982 [amended 2003]
and the Greater London Council [General Powers] Act 1982}. Body piercing
was hardly heard of at the time: although it was undoubtedly and somewhat
furtively practised, it was not as popular or as open as it is now. Guidelines
for beauty therapy, hygienic hairdressing and micropigmentation followed.
The main, and most urgent, problem with non-medical skin penetration
is hygiene – in particular the transmission of bloodborne viruses,
and especially hepatitis B. This virus is arguably the most infectious
organism known to man and can survive for long periods in the environment.
Fortunately, the guidelines formulated in 1978 and 1982 in the UK were
for hepatitis B, so that when the other two main bloodborne viruses,
hepatitis C and HIV, became known a little later, being much less resistant,
they were adequately covered by the guidelines.
HCV may be asymptomatic for years, and HIV may also be asymptomatic,
though usually for a shorter period. HBV infection in adults is less
commonly asymptomatic, but all three infections eventually cause serious
symptoms. The incubation periods for these three infections can be long,
which can make outbreaks difficult to recognise. Bacterial infection
must also be considered – in my experience, these usually arise
from poor aftercare or poor aftercare advice. Infection introduced at
the time of the piercing may lead to septicaemia and even to endocarditis
in susceptible persons, and also, of course, to wound infections. Infection
arising after piercing the cartilage of the ear is a particular and urgent
problem, brought about as frequently by poor aftercare as by an unhygienic
piercing.
The hygiene of non-medical skin piercing needs to be addressed urgently
in the EU, so that uniform and effective guidelines can be applied throughout
the Union. Otherwise, with different guidelines, standards of practice
will vary from country to country.
Other factors that need to be addressed urgently (not all to do with
hygiene) are
• Age of consent for each type of piercing, as well as competence
to give consent;
• The use of disinfectants, including alcohol for skin disinfection
and work surfaces, chlorine-based solutions for surfaces and blood spills,
etc
• The training and accreditation of practitioners, which follows from the
above;
• The use of anaesthetics, including ethyl chloride which is more
painful than the piercing and may cause freezer burns, and local anaesthetic
creams;
• Pre-piercing advice, including warning of the possibility of
complications (for ear-cartilage piercing in particular);
• Aftercare advice given to customers;
• Record keeping;
• Ethical issues, such as forming an accredited association of
competent practitioners who will ensure high standards so that members
of the public know they will receive a guaranteed service of competence
and safety, as well as those (alcohol and drugs) referred to by Worp
and colleagues. There should be one national association for each type
of practitioner, so that uniform standards are followed.
• Epidemiological studies of the rate and incidence of complications following
the different types of piercing. A study is currently being conducted
by the Health Protection Agency Centre for Infections in England and
Wales.
The use of non-sterile or chemically toxic pigments, as specified by
Worp and colleagues, undoubtedly also needs attention but I am not aware
of infection caused by pre-contaminated pigment and the problems of toxicity
and allergy need more research before making recommendations. Guidelines
for hygiene and the other factors mentioned should not have to wait for
these.
The authors are to be congratulated for their fine work in controlling
non-medical skin piercing in Amsterdam, and in particular for their work
in monitoring the performance of skin piercing establishments. |