Common complications of body piercing

Patient 1. A 25-year-old male college student is seen in the office with a 1 month history of a small bump on the left nasal ala just lateral to a piercing site. He had his nose pierced 2 months previously (figure 1). Blood and yellow fluid have been draining from the bump intermittently. The patient would like to have it removed.

Figure 1.

Small bump near a piercing site on the left nasal ala

What are the diagnosis and treatment of this bump?

Patient 2. A 20-year-old female college student presents to her physician because for 3 weeks she has had increasing redness of the left earlobe after reintroducing an earring that she had left out for 1 month. The earlobe has become red, tender, and swollen over the past week, and vesicles and a yellow crusty discharge have developed (figure 2). The patient has tender bumps at the angle of the jaw.

Figure 2.

Vesicles on the red, tender, and swollen left earlobe

What are the diagnosis and treatment of these lesions?

Patient 3. A 23-year-old college student visits her physician because for 5 days she has had increasing redness and tenderness of the mid to upper ear helix. She has had multiple piercings along the lateral helix. She is wearing one of her favorite earrings, which looks like a wrench.

What are the diagnosis and treatment of this area (figure 3)?

Figure 3.

Upper ear helix is red and tender

Patient 4. This patient, a 22-year-old woman, is seen in the office with a growth on her left ear that started 2 years ago from a previous ear piercing at that site.

What are the diagnosis and treatment of this growth (figure 4)?

Figure 4.

Growth on the left ear that started 2 years ago

ANSWERS Patient 1. Pyogenic granuloma

Also known as “proud flesh,” pyogenic granuloma is a common end result of an injury to the skin that may or may not have been apparent. Vascular proliferation, with or without infection, produces a small reddish violaceous or brownish black lesion that bleeds easily.¹ The isolated single lesion is usually less than 1.5 cm in diameter and may be dome shaped, sessile, or pedunculated.

The differential diagnosis includes nodular malignant melanoma (especially amelanocytic), squamous cell carcinoma, glomus tumor, nodular basal cancer, metastatic cancer, and bacillary angiomatosis.²

Treatment is shave excision and ablation of the base with electrodesiccation. The collected tissue specimen should be sent to a pathologist for a definitive diagnosis.³

Patient 2. Impetigo

Impetigo is a common, superficial bacterial infection seen most often in children. It is caused by group A β-hemolytic streptococci (impetigo contagiosa) or Staphylococcus aureus (bullous impetigo). Primary lesions vary from small vesicles to large bullae that rupture and discharge a honey-colored serous fluid. Secondary lesions appear as crusts from the discharge and appear to be lightly stuck on.¹ Body piercing is associated with other localized infections—from Staphylococcus and Pseudomonas species—and, rarely, with bacteremia and endocarditis. Piercing carries a risk of transmitting tuberculosis,¹ hepatitis C and B,⁴ and human immunodeficiency virus.⁵

The differential diagnosis includes contact dermatitis, tinea of smooth skin, and chronic herpetic ulcers.^1,2

To treat these lesions, remove crusts with soap and water and give the patient mupirocin (Bactroban) or a parenteral antistaphylococcal antibiotic, such as cephalexin, that also covers group A β-hemolytic streptococci.^2,3

Patient 3. Cellulitis

This acute spreading infection of dermal and subcutaneous tissues is characterized by a red, hot, tender area of skin, often at the site of bacterial entry. It is caused most frequently by group A β-hemolytic streptococci or S aureus.²

The differential diagnosis includes deep vein thrombosis, thrombophlebitis, stasis dermatitis, early contact dermatitis, erythema nodosum, erythema migrans, and prevesicular herpes zoster.²

The best treatment is use of an antistaphylococcal oral antibiotic, such as cephalexin, that also covers group A β-hemolytic streptococci.³

Patient 4. Keloid

A keloid is a tumor resulting from an abnormal overgrowth of fibrous tissue following injury in certain predisposed persons. It occurs more commonly in people with black African ancestry than in whites. Cosmetic procedures should be considered carefully in dark-skinned people or anyone with a history of keloids. Injuries that induce keloid formation include surgery, body piercing, lacerations, abrasions, cryosurgery, vaccination, and acne. Injuries of the ear, back, and upper chest are especially prone to form keloids.^1,3

The differential diagnosis includes hypertrophic scar, dermatofibroma, dermatofibrosarcoma protuberans, desmoid tumor, scar with sarcoidosis, and foreign body granuloma.²

Treatment involves combined cryotherapy followed by intralesional administration of triamcinolone, 10 to 40 mg/mL. The lesion is initially frozen and allowed to thaw for 15 minutes. Monthly intralesional corticosteroid injections (triamcinolone acetonide, 10-40 mg/mL) may reduce pruritus or hypersensitivity and the volume of the keloid, thereby flattening it.² The treatment of lesions that do not respond to cryotherapy and steroids is surgical excision followed by triamcinolone injection at the base to prevent regrowth.³

To prevent new keloid formation, patients should avoid further injury or piercing.