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Patient information: See related handout on body piercing, written by the author of this article.
Removal of jewelry at bedtime is indicated if switching to a different ear-ring style does not resolve the problem.
Piercing and tattooing in patients with congenital heart disease: patient and physician perspectives.
In the past, diaper contact dermatitis was usually localized to moist peri-genital and peri-anal skin locations. Presentation of pityriasis that shows the typical "Christmas tree" dermatone distribution on the back but more extensive rash on the arms and legs. Post treatment with antibiotics for MRSA and antifungal for tinea capitus, this child's inflammation has markedly improved but the child will likely still have patches of permanent alopecia due to severe damage to the hair follicles. Palmoplantar keratoderma is a chronic condition manifesting in early childhood with marked thickening of the skin of the palms and soles and areas of rash on body pressure points and sites of recurrent friction.
Acanthosis and circular lesions of superficial fungal infection complicate atopic dermatitis with hyperpigmented patches on his shoulders in this overweight youth with insulin resistance. The size and shape of jewelry is determined by the body site pierced and personal preferences. Parents of infants or young children with pierced ears should be informed of the risk of aspiration and ingestion of earring parts. Septal piercings usually are performed in the inferior fleshy part of the septum and not through cartilaginous tissue. Friction from clothing with tight-fitting waist-bands and subsequent skin maceration may account for the delayed healing and increased infection rates of navel piercings (Table 28,9). Abscess formation has been reported following nipple piercing.10 Except for case reports of cellulitis and spread of infection around an implant,32,33 little information is available about nipple piercing after breast implantation or chest wall augmentation.
One small study38 of children and adults with congenital heart disease found no cases of endocarditis after ear piercing, even though only 6 percent of patients received prophylactic antibiotic treatment. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
Superficial inflammatory conditions such as diaper dermatitis, seborrhea, tinea versicolor, and pityriasis alba are common conditions which frequently result in hypopigmentation that resolves over a period of a few months.
Contact Dermatitis:Contact dermatitis to a metal fastener on a pair of jeans that has produced hyperpigmented papules coalescing to a plaque on this child's abdomen.
Chicken Pox (Varicella) This child has hyperpigmented macules scattered over her body from chicken pox. Superficial LacerationA superficial laceration has produced hypopigmentationwith surrounding hyperpigmentation in this patient.
Atopic DermatitisThis teen has severe pigmentary changes from inadequately treated atopic dermatitis. This child has a patch of nummular eczema, with coalescing papules around the pilar opparatus (located just below the nipple on the chest).
Lichenification:This child with severe atopic dermatitis illustrates the tendency of children with dark skin to develop very unsightly lichenification where they have a chronic dermatosis and puritis.
Although they are often seen in the lumbosacral and gluteal areas they are not limited to those regions. Transient Neonatal Pustular MelanosisThe hyperpigmented macules and vesicles seen on the face and neck of this newborn infant are characteristic of transient neonatal pustular melanosis (TNPM). They can often be confused with herpes simplex, but usually can be distinguished on clinical grounds.
Timea corporis - Classic Presentation:Tinea corporis is extremely common in children of all ethnic backgrounds, but sometimes may have a different appearance in children with dark skin. Tinea Corporis without Erythema:Tinea corporis often presents without any erythema in children with dark skin as is illustrated in this photo.
Tinea Corporis at HarilineTinea corporis at the hairline, which goes into the scalp, needs to be treated systemically with oral anti-fungal agent such as griseofulvin. Herald Patch of Pityriasis RoseaThis lesion looks very similar to tinea corporis but actually is a herald patch seen at the onset of pityriasis rosea. Pityriasis Rosea - Classic PresentationThe oval shaped plaques of confluent scaling papules, distributed along the dermatomes, are characteristic of pityriasis rosea in children. Pityriasis Rosea - inverse distribution on armsChildren with dark skin often present with an inverse distribution of lesions in pityriasis rosea. The large patches on the right leg appeared first and were initially thought to be tinea corporis. Lichen Nitidus vs Lichen StriatusThis child has a line of skin colored papules stretching from the upper thigh to the ankle. Pityriasis AlbaThe hypopigmented patches on this child's left cheek is characteristic of pityriasis alba. For unknown reasons, tinea capitis is much more prevalent in the United States in African American children than in children of other races. The current epidemic of this illness often presents with a seborrheic-like scaling in the absence of alopecia. The lesions are less erythematous on the background of darker skin but typical "burrows" can be seen from the mite under the skin and secondary infection causes impetigo lesions where the child scratches their skin. Tinea Versicolor - hyperpigmentedThese lesions are examples of the hyperpigmented variation of tinea versicolor. Tinea Versicolor - HypopigmentedThe name tinea versicolor refers to the variable coloration of lesions. Pseudofolliculiltis BarbaePseudofolliculitis barbae is a foreign body reaction that occurs when arcuate hairs curve upon themselves and re-penetrate the skin. Hypopigmentation from Tretinoin (Retin A) UseThis teen's acne improved with Retin A, but hypopigmentation developed on the cheeks where it was applied more densely.
Henna and contact DermatitisThis East African girl developed a severe contact dermatitis with itching at the site of an elaborate skin decoration with henna. Coining in a ChildCoining is a common healing practice used among Asian patients within the United States.


Coining TechniqueThe lesions seen in coining are produced by rubbing a warm oil or Tiger Balm on the skin and firmly abrading the skin with a coin or special instrument as is illustrated in this photo. Circular Burns from Traditional HealingPatterned circular scars around the umbilicus in this East African child were produced by traditional treatments for illness. Circular Burns on ScalpThese circular lesions were produced by traditional burning treatments in an East African boy. ScarringThese diagonal scars at the top of the buttocks were from cuts made in the skin by the grandmother of this East African child "to help her walk" when she was about 9 months of age. Complications of body piercing include local and systemic infections, poor cosmesis, and foreign body rejection.
These piercings are associated with poor healing and more serious infection because of the avascular nature of auricular cartilage.
In such situations, earrings with a locking back or screw back are advisable.29Family physicians play an important role in promoting injury prevention by recommending that all jewelry be removed during contact sports to avoid endangering the wearer and other players. Piercing the cartilage can cause significant bleeding and lead to septal hematoma formation that often is accompanied by infection.
This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. This is one of the most dreaded keloid scar because it is in plain sight and it can cause psychological trauma too.
The factors are: black, age (puberty), location (sternum, stump of the shoulder, neck, ear lobe and lower face).
The papules will resolve with corticoid steroid treatment and removal of contact with metal, but the hyperpigmentation will last for months. These lesions can be prevented by appropriate vaccination of children 12 months and over with the varicella vaccine. This superficial inflammation usually resolves with temporary hypopigmentation at the site of lesions over 6 to 8 weeks. This lichenification and hyperpigmentation is very slow to resolve even with regular treatment with topical steroids. Intrauterinely acquired herpes infection can present with vesicles and pustules at birth, but most of these infants have intrauterine growth retardation and microcephaly. This is a typical lesion of tinea corporis: an annular shaped lesion with raised margins, clearing in the center and some erythema.
The lesions may be more difficult to see in children with darker skin pigmentation and as noted earlier, often have a more papulofollicular appearance. Rather than appearing on the trunk, as in the prior photo, they primarily are distributed on the arms and legs as is illustrated in this photo. It usually does not respond to topical steroids and resolves without treatment over a period of months, but the duration of lesions is variable. Fifteen percent of African Americans who visited an outpatient clinic for non-dermatological reasons were found to be infected in a recent study. This non-inflammed presentation leads to delayed diagnosis and spread within the household. The plaques and patches are slightly raised, usually circular, often on the neck and upper face, but commonly on the chest, back, and under the breasts in adolescent girls.
This creates pustules and papules as illustrated on the back of the head of this young man who has shaved his scalp. The hypopigmentation resolved with shortening the duration of Retin A application to 2 hours and adding an oral antibiotic to prevent the inflammatory lesions. This is commonly seen with tight hair braids or tuffs and is found in individuals from many different ethnic backgrounds. Initially they were confused with alopecia from tinea capitis but the history indicated that they had been produced by a traditional treatment for chronic ear infection. Scars are also common on the face as cosmetic and religious decoration in many African groups. Like coining, cupping is done to release wind from the body and thereby restore balance and health. In particular, jewelry designed for ear piercing may not be suitable for another part of the body because of the length of the post or the pressure exerted by the clasp.Most body piercing jewelry is made of metal, usually stainless steel, gold, niobium, titanium, or alloys. If lingual jewelry cannot be removed easily or expeditiously, precautions should be taken during intubation to ensure that jewelry is not loosened and aspirated or swallowed. Auricular perichondritis and perichondrial abscess typically occur in the first month after piercing, especially during warm-weather months.7 Auricular perichondritis presents as painful swelling, warmth, and redness in a portion of the auricle that often spares the earlobe. Other potential complications that may result in cosmetic deformity include perichondritis and necrosis of the cartilaginous nasal wall. The problem of jewelry migration and rejection is compounded by wearing heavily weighted, thin-gauge jewelry. It is a very common practice in many ethnic groups to do ear piercing in early infancy which may help to avoid keloid formation. Compared to a bruise they are more uniform in skin color, their borders are better defined, there is no induration or tenderness and they are stable over time. They are more common in term infants and are almost always seen at birth or soon after birth.
Perinatally acquired herpes infection usually does not present with vesicles until day of life 5 - 17. The lesions of lichen striatus appear similar to those of lichen nitidus, but have a linear distribution. Early treatment of acne, when it is mild, is important to prevent the long lasting hyperpigmentation and scars. The alopecia can be permanent if there are large areas that are not recognized and treated appropriately by loosening the traction on the hairs.
When applied to the fingertips, black henna has been found to interfere with measurement of oxygen saturation from a fingertip. It is also used with a wide variety of febrile illnesses as well as stress related symptoms in adults such as headaches, muscle aches and pain, low energy.


The child complained that this cupping, done by a grandmother hurt, but that it did not hurt when done by mother. Minor infections, allergic contact dermatitis, keloid formation, and traumatic tearing may occur after piercing of the earlobe. Acute tenderness on deflecting the auricular cartilage helps distinguish this deeper perichondrial infection from a superficial skin infection.
Infection requires aggressive treatment with antibiotics that have good coverage against Staphylococcus species that commonly colonize the nasal mucosa.
Migration of navel rings and subsequent scarring are more problematic in overweight patients and in the latter stages of pregnancy as abdominal girth expands (Figure 4) . Condoms may be more prone to break and diaphragms may be more easily dislodged during sexual activity when one or both partners have genital piercings.
Ear piercing systems using disposable sterile cassettes are available.Family physicians should help patients make informed decisions about body piercings and counsel them about the importance of universal precautions.
Adequate topical corticosteroids, oral antihistamines and moisturizing agents to prevent itching, and early recognition and treatment of secondary bacterial skin infection can help prevent this cosmetically disfiguiring change in pigment. Although pustules are present and a culture may show bacteria, it is not necessary to treat with antibiotics.
Treatment consists of avoiding a close shave, shaving with an electric razor and applying a depilatory chemical cream.
Benzoyl peroxide which is commonly used in over the counter acne preparations, is a bleaching agent and produces lightened skin color with overuse. However, some patints with contact dermatitis who have subsequently had patch tests with lawsone, the active ingredient in henna, have not shown a reaction. The practice produces linear petechiae and ecchymosis on the chest and back which resolve over several days. Nickel in gold-filled or gold-plated jewelry is associated with a high prevalence of reactivity in persons who are nickel sensitive. Minor infections can progress to perichondritis, abscess formation, and necrosis with or without systemic symptoms.
Physicians should remain nonjudgmental so that patients are not reluctant to report a problem.
Excoriated acne, impetigo, varicella, lupus, infected atopic dermatitis, contact dermatitis, and scars from burns, lacerations and abrasions are common conditions which cause long-lasting hyperpigmentation.
This child developed many other skin colored papules over the trunk during the next few months. The patches tend to be more prominent in the summer and fall as the child's normal skin tans and gets darker with the sunlight exposure whereas the affected areas remain paler. In newborn infants there is enough transcutaneous absorption of the active agent in henna, lawsone (a potent oxidizing agent), to produce hemolysis of red blood cells and indirect hyperbilirubinemia.
This suggests that there are other unetermined ingredients in henna powders which are allergens.
Fluoroquinolone antibiotics are advised for treatment of auricular perichondritis because of their antipseudomonal activity.
Consumers must pay careful attention to the stud or clasp on earrings; jewelry with a high karat rating commonly is paired with less expensive gold-plated studs or earring backs. Fluoroquinolones have the advantage of excellent skin penetration and added coverage against Pseudomonas species.Nasal jewelry has the potential to be aspirated or swallowed. Because body piercing salons are unregulated in many states, some physicians may choose to perform body piercing procedures in the office setting.
When they were biopsied the histopathology of the lesions was found to be characteristic of lichen nitidus.
The presence of the lesions usually indicate that the child was very sick at one time and western medical treatment was not available or had not been effective. Many complications from piercing are body-site–specific or related to the piercing technique used. Niobium and titanium are light-weight elemental metals that rarely produce an allergic response.
Informing the parents to anticipate hypo-pigmentation as a part of the natural healing process helps to improve compliance with topical treatment. However, it may produce intense inflammation which can result in hyperpigmented patches on the face that are very slow to resolve or hypopigmentation as in the case above.
It is useful for the provider to ask about how the child was ill at the time they received the treatment. Treatment with 2 percent mupirocin ointment (Bactroban) or oral antistaphylococcal antibiotics may be warranted.NONINFECTIOUS COMPLICATIONSThe earlobe is a common site for hypertrophic scarring and keloid formation. Stronger forms of tretinoin (0.1% cream) have been used to successfully lighten post inflammatory hyperpigmentation from acne in adults with 40 weeks of nightly treatment.
Treatment options for keloids include surgical excision, intralesional corticosteroid injections, cryosurgery, pressure dressing, radiation, and laser therapy.22,23Contact dermatitis resulting from nickel exposure is common. Embedding may be prevented by using longer earring posts with adjustable backings.If gentle probing fails to locate an embedded ear-ring, a small incision under local anesthesia (without epinephrine) may be necessary to locate and remove the earring or backing. An earring can be replaced or the ear repierced six to eight weeks after resolution of local swelling and tenderness.21Trauma to the pierced external ear is common. Lacerations to the ear may occur after falls, motor vehicle crashes, contact sports, person-to-person violence, or accidental pulling of an earring. The simplest laceration occurs when an earring is pulled through the earlobe, especially if the original earring hole was close to the periphery (Figure 3) . If the hole has closed, the ear lobe can be repierced in a nonscarred area after approximately three months.27 Various closure techniques have been described in the literature28 for more complex lacerations of ear cartilage.
Many family physicians refer these complicated injuries to subspecialists for repair.Pointed earring posts may cause pressure sores or postauricular skin irritation when worn during sleep.



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