attitudes and practices regarding nose piercing: results of ...background: body piercing confi ned...

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Attitudes and Practices Regarding Nose Piercing: Results of a Questionnaire Survey and Review of the Literature

Cemal Cingi1 Murat Songu2, 3 Can Cemal Cingi4 Hamdi Cakli1 Onder Ihvan1

Background: Body piercing confi ned to the ears, mouth, and nose has been a common practice in almost every society around the world as far back as can be traced. As the popularity of pierc-ing increasing, there is a soaring urgency of understanding the subsequent complications.Objective: A survey was designed to analyze the attitudes and practices of a group of volunteers wearing nose piercing. The questionnaire aimed to establish where and how the individuals had their piercing and what kind of complications they had when they got pierced, if any. Also evalu-ated are the psychosocial consequences of piercing and the reason behind the body jewelry.Methods: A 15-question survey was offered on a voluntary and anonymous basis to individu-als wearing nose jewels at various public places in Eskisehir and Izmir, Turkey, over a span of 4 months period. Questionnaire data were analyzed using the SPSS 15.0. Independent variables included various health complications, location of the piercing and the instrument by which the piercing is performed.Results: A total of 74 female volunteers responded to the questionnaire. There were 87% had the procedure performed in an unregulated shop while 65% had it done by non-professional person-nel. In 85%, the procedure was executed with a sterile injection/needle or a piercing gun, assum-ing both were sterilized instruments. Nearly 70% noted at least one symptom of local infection. A 30% observed bleeding. No correlation was found between various complications and the lo-cation of the piercing or the instrument by which the piercing is performed (p<0.05). Over 90% were clearly happy with their piercing. Adornment is the number one reason (in 38%) of having nose piercing.Conclusion: Results showed that body piercing, which was common among adolescents, may pose a signifi cant risk to one’s health. Studies with larger sample size and among different popu-lations with various cultural backgrounds are needed to delineate the rate of health complications we have observed. Exploration of psychological and sociological consequences of body piercing through long-term follow-up would be desired. (Dermatol Sinica 27: 210-217, 2009)

Key words: Nose piercing

Original Study

From the Department of Otorhinolaryngology, Osmangazi University Medical Faculty, Eskisehir, Turkey,1 Department of Otorhi-nolaryngology, Dr. Behçet Uz Children’s Hospital, Izmir, Turkey,2 Department of Otorhinolaryngology, Izmir Ataturk Research and Training Hospital, Izmir, Turkey,3 Department of Visual Communication Design, Yeditepe University, Istanbul, Turkey4

Corresponding author: Murat Songu, MD, Department of Otorhinolaryngology- Head and Neck Surgery, Dr. Behçet Uz Children’s Hospital, Izmir, TurkeyTEL: +90 532 685 84 84 FAX: +90 232 489 23 15 E-mail: [email protected] source: noneConfl ict of interest: none declared

Received: May 30, 2009Revised: August 11, 2009Accepted: August 28, 2009

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INTRODUCTIONBody piercing confined to the ears,

mouth, and nose has been a common practice in almost every society around the world as far back as can be traced.1 Archaeologists and historians have noted that body piercings have been performed all around the world for over 5,000 years.2 However, these practices have experienced an enormous popularity over the last 30 years, especially in West-ern societies. Body piercing and other body modifications have increased through all social classes and age groups with the major concentration among adolescents and young adults. Although a demographics survey re-ports 2% of the American public with body piercings, findings from college populations with piercings is 33%.3-5 As the popularity of piercing is increasing, there is a soaring urgency of understanding the subsequent complications. These complications primar-ily related to the materials and/or instruments used, the body region(s) pierced, practitio-ners’ experience, personal hygiene, and after-care.

In this study, we designed a surveil-lance questionnaire to recognize young vol-unteers’ attitudes toward nose piercing, their piercing practices and complications they might experience.

MATERIAL AND METHODStudy Design

A questionnaire, drawn up and refined specifically for this study, was offered on a voluntary and anonymous basis. The respond-ers were individuals wearing nose piercing at various public places, mostly university halls and organizational meetings between Octo-ber 2008 and January 2009 in the cities of Eskisehir and Izmir. They responded to the questionnaire in a voluntary basis.

The responders were from two cities, Eskisehir and Izmir. Eskisehir is a province in northwestern Turkey with a population

of 741,739. Izmir is in west Turkey by the Aegean Sea and the third most populous city with a population of 2,649,582. The survey instrument was designed to be brief, non-intrusive, and easy to complete in order to ensure a high response rate. The initial part of the questionnaire documented age/gen-der. Responders’ names were not recorded. The questionnaire consisted of six multiple-choice questions, eight yes-no questions and one open-ended question (Table 1).

Statistical analysisQuestionnaire data were analyzed using

the SPSS 15.0 (Statistical Package for Social Sciences) for Windows. Demographic pa-rameters were summarized with descriptive statistics and frequency tables. Various com-plications, location of the piercing and the in-strument by which the piercing is performed were categorized as independent variables. Chi-square statistics and eta coefficients were generated for each variable, to test the statis-tical significance of the cross-tabulation, and its usefulness in further analysis. P values less than or equal to 0.05 were considered as statistically significant.

RESULTSThere were 74 female volunteers, aged

between 18 and 30 years (mean 21.90 ± 2.73) responded to the questionnaire and complet-ed it properly.

* 92% of the responders had their piercing on the right side.

* Nose piercing was done 1 to 120 months before the survey with a mean of 23.6 ±19.0 months.

* Only 13% had the procedure performed in a regulated shop - in a pharmacy, doctor’s surgical office or in tattoo studio. The rest had it done in a bijouterie shop (84%) or at home (4%) (Fig. 1).

* Only 35% had the procedure performed

212Dermatol Sinica, Dec 2009

Attitudes and Practices Regarding Nose Piercing

by a professional- a medical personnel, piercing technician or a pharmacy assistant while the rest had it done by a salesman (61%) or by responders herself (4%) (Fig. 2).

* 85% had the procedure done with a sterile injection needle or a piercing gun, assum-

ing both were sterilized instruments. * 70% had experienced at least one sign or

symptom of local infection such as pain (51%), redness and tenderness (64%) and swelling (38%).

* 30% noted annoying bleeding while pierc-ing.

Table. 1 The Questionnaire


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No correlation was found between complications and the location of the pierc-ing or the instrument by which the piercing is performed (p<0.05).

Among people answered the question-naire, 93% declared their absolute happiness with their piercing. All stated that they would do it if they had not done it. Among these individuals, 11% had an additional piercing on their face and 34% had another piercing on their body. When reasons for having nose piercing were asked, adornment took first place with 38%. Expression of freedom came as second with 26%. To be and feel differ-ent appeared as third in 24%. Some did it as a protest in view of their parents against it (12%).

DISCUSSIONTo the best of our knowledge, this is

the first surveillance look into the attitudes, practices and complications of nose pierc-ing. However, our study subjects are small

in number and restricted to a limited geo-graphic/cultural/religious population. The data should be interpreted appropriately and not extrapolated to other populace.

However, we would like to deliberate several points here based on our findings:

First point is the great potential for in-fection. Our study strongly suggested a risk for infection. A great majority experienced signs and symptoms of local infection like pain, tenderness, redness, swelling, etc. The degree to which a person shows some or all of these symptoms depends greatly on how severe the infection is and how much resis-tance to infection a person has. However, due to the nature of this study, i.e., a surveil-lance dealing with past events, we could not confirm these symptoms/signs were indeed the manifestation of infection. Piercing was mostly performed in unregulated areas: bi-jouterie shops, beauty salons, department stores, jewelry stores, and even at homes. Rarely physicians’ offices, pharmacies or tattoo studio were the place where the pro-

Fig. 1Places Where the People Questioned had Their Piercing Performed.



cedure was done, as shown in our study. Further, only a third of the procedure was done by a professional- a medical personnel, piercing technician or a pharmacy assistant. There are no official agencies that grant cer-tification for clinics or professionals. It is up to the piercer to practice aseptic techniques and sterilize equipment correctly. Piercing is an invasive procedure that predisposes the client to local infections and blood-borne diseases. Even though a good majority of responders claimed that the procedure was performed with a sterile injection needle or a piercing gun, they would not know for sure it was fully sterilized. A piercing gun is very difficult and usually expensive to sterilize it properly. Therefore, local infection rate could be as high as 70% as indicated by the present study. Local infection was the most common cause of complications and reported in 10-78% of piercings in earlier studies.6, 7 Specific skin pathogens such as Staphylococcus au-reus could involve surrounding tissue and lead to more serious carbuncles, impetigo, cellulitis or even abscesses. Furthermore, nose and ear piercings were prone to infec-tions with Pseudomonas aeruginosa, result-

ing in a necrotic chondritis that might require surgical intervention. In extreme cases, in-fection could become systemic, especially if local infection was not properly treated or persons were immunocompromised. Cysts, keloids and hypertrophic scars were also reported as local complications.8 Bacterial in-fection was documented as the most common adverse problem.9 Transmission of hepatitis B, C, D, and G and eventual fatal fulminant hepatitis via piercing have been reported.10-13 There was no report of HIV case via pierc-ing, but the potential definitely existed. The concern about person-to-person transmission of viral infections has led the Food and Drug Administration to restrict blood donation for 1 year after tattooing or piercing. Transmis-sion of tetanus, leprosy, and tuberculosis has also been reported through piercing.14-16 Sahn et al. in 1974 documented a case of tuber-culosis with drug-resistant tubercle bacilli which was inoculated through nasal pierc-ing.16 Kaur et al. described a case of lupus vulgaris as a consequence of nose piercing.17 None of our responders mentioned symptoms which could have suggested the presence of blood-transmitted infection.

Fig. 2By Whom the People Questioned had Their Piercing Performed.


Cemal Cingi, et al

The symptoms and signs experienced by our responders could also be those of allergic reaction or irritation. But allergic sensitization due to contact with metal and nickel sulfate has often been reported in the literature. Such risk prompted the establish-ment of the European Nickel Directive which set up threshold values for nickel content and nickel release of costume jewelry. Besides eczematous eruptions, those metals may also elicit allergic granulomatous reaction veri-fied by a positive patch test. Granulomatous perichondritis of the nasal ala, with an infec-tious etiology being ruled out, was reported by Folz.18 A complete surgical resection was the only alternative if other measures failed to solve the reaction.

Another point to emphasize based on our findings is bleeding as a common side-ef-fect. Even hemorrhage would be expected in each piercing, it can be considerable in cer-tain sites. Stirn et al. reported that bleeding after body piercing procedures could occur in 10-30%.19 Precaution should be taken in that severe hemorrhage could occur in hemo-philiac, after taking aspirin or anticoagulants and in compromised persons with bleeding tendency. One third of our responders experi-enced a temporary and mild bleeding. There is no correlation between bleeding and the location or the instrument of the piercing.

Although most problems associated with piercing are usually minor and self lim-iting, some complications are serious and can be fatal. Our study was not designed to iden-tify such rare complications, but piercers, people choosing to be pierced and healthcare providers need to be aware of the possible serious negative outcomes of body piercing. Infective endocarditis resulting from nasal piercing has been described.20 An antibiotic prophylaxis was recommended for people with congenital or acquired cardiac disease.21,

22 But abstain from body piercing should be advised for those individuals. Nodular (pseu-

dosarcomatous or proliferating) fasciitis in the supralabial region, an atypical cellular neurothekeoma arising subsequently in the area of a nasal alar piercing, and a basal cell carcinoma at the site of a nasal piercing all have been documented in the literature.23-25

The study attempted to evaluate the psychosocial consequences of the individu-als. Our responders seem to be happy about their decision of nose piercing. Some even went on to have further body piercing. This is in contrary to the reports of unhappiness, embarrassment, low self-esteem, and disap-pointment with piercings.16 Body piercing can be interpreted as a visible, self-produced violation of socially defined beauty stan-dards and body boundaries and, thus, arouses social provocation.19 Millner surveyed 81 subjects recruited through body art shops and revealed that key motivating factors for obtaining body piercing were individual expression (62%) and art (43%).26 Less com-mon motivations included the perception that body piercing is sexy and beautiful, i.e., a form of celebration. Armstrong and his col-leagues reported motivations for body pierc-ing among college students included unique-ness” and “to be myself”.27 These findings more or less agreed with ours: our respond-ers’ idea about nose piercing was adornment, expression of freedom, to be and feel differ-ent and as a protest against their own parents.

Apart from the topic and the design of this survey study, special implementa-tions for nasal piercings in the operating room and in radiologic diagnostic studies are worth to mention. Nasal piercings have caused problem in the operating room and during radiologic diagnostic procedure.28, 29 Nose piercings/jewelry were advised to be removed before such procedures. They might be forced in as foreign body during anes-thetic process and/or intraoperative airway management.30-32 Kuczkowski et al. presented a parturient case underwent emergency ce-



sarean section who then required fiberoptic endoscopy and radiologic imaging studies to rule out aerodigestive tract aspiration of the intranasal backing of her nasal jewelry.31 Another incident was reported lately by Dhir & Dhir.32 The nasal jewelry was lost dur-ing surgery and entangled in the nasogastric tube. It was located at the time of the tube’s removal. Patients who require radiological examinations might be advised to have their body jewelry removed because it might lead to misinterpretation.

The present study has several limita-tions. The primary limitation is that the sample population is small and this restric-tion impairs the strength of the statistical analysis. The second limitation is that the sample size is comprised all female and all from a Muslim country. The characteristics of this population cannot be extrapolated to other populations but gives an idea about the big picture.

CONCLUSIONThe results of our study are just small

steps toward a better understanding of the impact of nasal piercing. Education targeted to populations inclined to body piercing is advisable. Health professionals need to ap-preciate the potential complications of body piercing, the proper way of piercing and ap-propriate adversity management. The popu-larity of piercing warrants a comprehensive systematic documentation of health and psychosocial risks. Further studies would preferably have a larger sample size, can do long-term follow-up and have a population comprising multicultural background.

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