An Bras Dermatol. 2014;89(6):905-910.
Piercings in medical students and their effects on the skin*
Kátia Sheylla Malta Purim1,2 Bernardo Augusto Rosario1
Cristine Secco Rosario2Ana Tereza Bittencourt Guimarães2
Abstract: BACKGROUND: Piercings are body embellishments commonly seen in young people, however their inher-
ent risk of infection and scarring disorders are less divulged. OBJECTIVE: to evaluate the prevalence of body
piercings among medical students and their possible dermatologic consequences. METHODS: cross-sectional
study with 58 medical students, by means of a structured questionnaire covering socio-demographic characteris-
tics, technical issues related to the piercing and characteristics of the dermatologic complications. RESULTS: the
sample was predominantly female (86.2%), with mean age 24 ± 3 years. The placement of the first piercing
occurred during adolescence (median age 15), without medical supervision (91.4%) or knowledge of
parents/guardians (74%). Most piercings were made of metal alloy/stainless steel, in a dumbbell model (51.7%),
inserted in the umbilical area (53.5%) or ear (41.4%), with frequent cutaneous reactions in the first six months post-
piercing. Hypertrophic scarring, pain, swelling and infection (p<0.05) had significantly higher frequencies among
those with navel piercings. CONCLUSION: piercing insertion occurred during adolescence. Local inflammatory
and infectious reactions were common. Scarring disorders and dermatitis appeared in the long term. There is need
for preventive and educational activities, starting with those in the academic environment.
Keywords: Body piercing; Medical students; Scarring
Received on 17.06 .2013.
Approved by the Advisory Board and accepted for publication on 07.12.2013.
* Work performed at Universidade Positivo (UP) in association with Universidade Federal do Paraná (UFPR) – Curitiba (PR), Brazil.
Conflict of interest: None
Financial funding: None
1Universidade Positivo (UP) – Curitiba (PR), Brazil.
2Universidade Federal do Paraná (UFPR) – Curitiba (PR), Brazil.
©2014 by Anais Brasileiros de Dermatologia
For the last decades, the popularity of body
piercings has been in expansion in many countries,
socioeconomic strata and age groups, with prevalence
rates ranging from 25% to 51% among adolescents and
young adults.1-6 In ancient civilizations this accessory
entailed military, religious and socio-cultural issues,
having sparked prejudice due to a possible association
with signs of rebellion and risk behaviors.7-10 Currently,
its wear is motivated by several factors, mainly the
desire to try something new in order to take control of
the body and identity, but also by passing trends or
fads, influence of friends, inclusion into specific
groups, greater acceptance in society and the stimuli
provided by the media.1,2,11,12
The word “piercing” derives from the English
verb “to pierce”, which means to transfix and this is a
deliberate and somewhat semi-permanent procedure,
considered a factor that causes alteration of local
homeostasis and exposure to communicable dis-
eases.2,13 The risks to piercing wearers are grouped into
categories associated with purchase, possession and
health care.14 The risk stemming from purchase is
related to piece’s price and the procedure that the
individual undergoes to have it inserted.1,6,14 As to pos-
session, although the embellishment has a symbolic
value to the owner, others may perceive that body
symbol in a negative way, with impacts on relation-
ships and self-esteem.7,9,10,12,15 However, attention to
health risks is a priority due to the necessity to reduce
lesions, increase protection and prevent eventual
physical, emotional and cosmetic damages.12,14,15
Depending on the body region, manner of
insertion and maintenance conditions, the presence of
a piercing can justify disorders and adverse effects
that may go on for days, weeks or months after
implantation.1,6,8 The cutaneous areas that are most
reaction-prone are the navel, ear and nose.1,14 Studies
have demonstrated the occurrence of cutaneous infec-
tions, cysts, edema, granuloma, hematoma, keloids,
hypertrophic scars, abscesses, contact dermatitis and
allergic reactions.6,16,17 In intra and perioral regions,
research evidences: pain, edema, airway obstruction,
grooved or fractured teeth, gingival trauma, tongue
and lip injuries, interference with mastication, speech
and salivation, halitosis, periodontitis and foreign
body aspiration.18-20 Medical reports of piercing com-
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An Bras Dermatol. 2014;89(6):905-910.
plications in the pinna include perichondritis, cauli-
flower deformity, infectious disorders, scarring and
various aesthetic deformities.14,20 Studies also draw
attention to possible systemic outcomes such as bacte-
rial endocarditis, tetanus, hepatitis B and C, tubercu-
losis, HIV infection, toxic shock syndrome,
osteomyelitis and acute diffuse glomerulonephritis in
The detrimental aspects of piercing are associat-
ed with the lack of knowledge on preventive meas-
ures. Body piercing requires universal health precau-
tions and appropriate positioning, in restricted non-
cartilaginous areas.29-32 The decorative piece should be
made of surgical stainless steel, gold, titanium or
acrylic and regardless of the chosen type, it needs to
be removable to be periodically cleansed.1,2,18
Approximately 10-30% of piercing cases present infec-
tion or bleeding in the insertion site.1,19,31,33 These
adornments are contraindicated in pregnant women,
immunocompromised patients, those who are prone
to keloid formation, infectious dermatitis, atopic der-
matitis, and dermographism and also during sports
practice.1,18,33 Piercings are not recommended to
patients with blood dyscrasias, congenital heart dis-
ease and those using anticoagulants.1Individuals with
piercings, which were implanted in safe sanitary con-
ditions, must wait at least six months to donate blood.1
Current law establishes regulations and periodic
inspections of tattoo and piercing establishments. 1
Nevertheless, there is not yet a federal legislation
about the insertion of these body adornments in chil-
dren and adolescents.18
Despite frequent patients’ complaints on cuta-
neous reactions and scarring secondary to piercing
wear, we realize the need for more research to divulge
the risks involved in this practice. This knowledge is
important in the medical environment because such sit-
uations can have serious physical and emotional conse-
quences, and require specific approaches for their pre-
vention and treatment.1,29,32-35 The aim of this study is to
evaluate the prevalence of cutaneous piercing and the
ensuing consequences among young medical students.
SUJECTS AND METHODS
This study is a descriptive cross sectional sur-
vey research, targeting the population of medical stu-
dents in a private institution in southern Brazil. The
research ethics committee approved this project (pro-
tocol number 041/2011) and assured confidentiality
and anonymity to the volunteers.
Piercing was defined as any type of adornment
(body piercing), jewelry, accessory or decorative
piece, inserted in the skin or mucosae, through a prob-
ing object (gun, needle, pin, ornament itself, piercing
stylus etc.), in different parts of the body other than
the earlobes. Ornaments in the second earlobe orifice
or the use of earlobe stretching plugs were not consid-
ered as piercings.
Assessment of tobacco consumption followed the
World Health Organization (WHO) criteria. The empha-
sis on tobacco was due to its important role in skin heal-
ing, with those having smoked a minimum of five packs
or 100 cigarettes during their lifetimes defined as smok-
ers, and those who meet the definition of a smoker, but
were not current users, as former smokers.
Physical activity was defined according to
World Health Organization (WHO) criteria as the
completion of at least 30 minutes of moderate intensi-
ty exercise on most days of the week.
Sample selection was non-probabilistic, by con-
venience and occurred through detailed explanations
about the research. We initially approached 161 stu-
dents of both genders and of any color/race/ethnici-
ty, between classes in the university hospital between
February and March 2012, on the daily wear of pierc-
ings. Those who answered affirmatively were asked
to participate in an assessment and screening session
for the study. We included 58 volunteers over 18 years
old, who had regularly worn piercing for more than
six months and agreed to participate by signing the
term of free and informed consent, according to
Data were collected through a structured ques-
tionnaire, pre-tested by three professors of medicine
and applied as a pilot in five students. This data col-
lection instrument was comprised of closed questions
to check the students’ sociodemographic features such
as gender, age, ethnicity, marital status, and behav-
ioral and health aspects, including immunization cov-
erage; and technical issues regarding piercings (type,
location, quantity, hygiene procedures). To verify the
complications and medical treatments secondary to
the piercing procedure, we used clinical and cuta-
neous data recall, medical history and physical exam-
ination. After data collection and assessment, students
were informed about preventive measures regarding
infections and dermatoses.
The results were analyzed using descriptive
statistics, according to the nature of the evaluated
variables. Quantitative variables were expressed as
means and standard deviations, and categorical vari-
ables using absolute and relative frequencies. The
absolute frequencies of skin lesions’ categorical vari-
ables in the different anatomical locations (ear, navel
and others) were compared between piercing wearers
through the Chi-Square Test for k proportions, fol-
lowed by multiple comparisons between analyzed
category frequencies by the Marascuilo procedure.
The duration of lesions was compared between the
groups that worn piercings on ears, navel, ears +
906 Purim KSM, Rosario BA, Rosario CS, Guimarães ATB
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Piercings in medical students and their effects on the skin 907
navel and other sites by variance analysis for a single
factor. In all analyzes, we used the significance level of
p <0.05. These categorical variables were expressed in
cross tables and, when necessary, by column charts.
All statistical analyzes were performed using the sta-
tistical program XLStat2010.
The sample consisted of 58 students of a private
medical institution, who had worn piercings regular-
ly for more than six months. The average age of stu-
dents was 24 ± 3 years; eight were males (13.8%) and
50 females (86.2%). There was a predominance of
Caucasians (76.8%), singles (96.6%) and those enrolled
in the course’s 6th or 7th semesters (51.7%), (Table 1).
Regarding health features, eight students
(13.8%) had diagnoses of chronic illnesses (asthma,
hypothyroidism, rhinitis, epilepsy, myopia, polycystic
ovarian syndrome, migraine, psoriasis and depres-
sion), and 29 (50%) were taking medications daily,
especially contraceptives among women (38%) and
anti-inflammatory drugs in both genders (16%).
Forty-eight students (82.8%) were up-to-date with
their basic immunization schedule.
As for lifestyle characteristics, six students were
smokers (10.3%); four of these (66.6%) had been smok-
ing for a period 1-5 years and two (33.3%) smoked more
than ten cigarettes per day. Among the subjects ana-
lyzed, 27 (46.6%) practiced physical exercises regularly,
85.2% of them exercised three or more times per week.
Assessment of piercing wear characteristics
found that, on average, the first adornment was
implanted at 14±3 years of age, for reasons such as
fashion trend (44.8%) or willingness to experiment
(25.9%). The minimum age for piercing insertion was
12 years old, maximum of 23 years and median of 15
years. Thirteen students (22.4%) inserted another
piercing about a year after the first procedure. The
amount of body piercings was one to two (84.2%),
with a preference for metal/stainless steel piercings,
in dumbbell shape (51.7%) located in the navel (53.5%)
or ear (41.4%), (Table 2).
About the decision-making process on the pierc-
ing insertion, 29 (50%) students did not seek any infor-
mation, twenty (34.5%) sought information on the
Internet, thirteen (22.4%) talked about the question
with friends and five (8.6%) requested information
from physicians. Fifteen students (26%) did not discuss
the insertion with their parents before the procedure.
In assessing the characteristics of insertion pro-
cedures, data showed that body piercing was per-
formed in specialized studios (84.5%), with qualified
professionals (63.8%). Among the participants in the
sample, 27 completed a registration form on the use of
piercing (46.6%) and 32 received leaflets (54.4%).
Upon insertion of the piercing, the professional wore
gloves (94.8%), disposable materials (85.4%), topical
anesthetic (25.9%), and wound dressings (26.4%).
Variables Category FA FR%
Gender Feminine 50 86.2
Masculine 8 13.8
Age (years) 20 – 22 23 39.7
23 – 25 28 48.3
26 – 28 5 8.6
> 28 2 3.4
Race Yellow 3 5.2
White 43 74.1
Brown 10 17.2
Did not respond 2 3.4
Marital status Married/widow 2 3.4
Single 56 96.6
Origin Curitiba 29 50.9
Other cities in 16 28.1
Other cities in 12 21.1
Which semester 2nd – 4th 5 8.6
are you attending? 5th - 6th 11 19.0
7th - 8th 27 46.6
11th - 12th 13 22.4
Did not respond 2 3.4
1: Absolute (FA) and relative frequencies (FR%) of socio-
demographic variables in a sample of piercing wearers (n=58)
Variables Category FA FR%
Reason Beauty 13 22.4
Influenced by friends 3 5.1
To record an event/time 2 3.4
Fashion trend 26 44.8
I wanted to 15 25.9
Material Silver 8 13.8
Metal/Stainless steel 47 81.0
Gold 8 13.8
Plastic 1 1.7
Model Ring 11 19.0
Dumbbells 30 51.7
Straight 14 24.1
Ball 8 13.8
Horseshoe 11 19.0
Site Mouth/lips 2 3.4
Tongue 5 8.6
Nipples 1 1.7
Ear 24 41.4
Navel 31 53.4
Nose 6 10.3
Perineal region 1 1.7
Eyebrow 2 3.4
Number of 1 35 60.3
pierced holes 2 13 22.4
3 or more 9 15.5
Did not respond 1 1.7
2: Absolute (FA) and relative frequencies (FR%) of varia-
bles about reason for wearing and piercing characteristics in the
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An Bras Dermatol. 2014;89(6):905-910.
908 Purim KSM, Rosario BA, Rosario CS, Guimarães ATB
Regarding hygiene habits, 33 students cleansed
the adornment daily (57.1%), 36 did not change the
piercing (61.4%) and one of the students changed it
daily (1.8%). Fifty-three students had worn the pierc-
ing for more than five years (91.4%). None of the 58
students in the sample had clinically apparent record
of systemic complications.
Assessment of cutaneous lesions secondary to
piercing wear showed that 29 students (50%) had local
reactions such as infections (55.2%),
pain/swelling/inflammation (37.9%) and hyper-
trophic scar/keloids (24.1%) in the first six months
after the insertion (65.5%), (Graph 1).
However, when evaluating the therapeutic
approach, we observed a spectrum ranging from no
intervention at all (41.4%), use of antibiotics (13.8%),
antiseptics (13.8%), and other ointments (10.3%), to
removal of the adornment (10.3%). Unsightly scars
(20%) and contact dermatitis (7.7%) also developed six
months after insertion, requiring specialized and pro-
longed treatment. In all insertion sites (ear, navel, ear
+ navel and others) the mean duration time of the
lesions was similar, ranging from 2 to 12 months (7 +5
months) (F 3,24=0.83, p=0.490) (Graph 2). Unwanted
scars were located mainly in ears and navel.
Comparisons between lesions arising in differ-
ent insertion sites demonstrated homogeneity in all
categories among piercing wearing groups (Table 3).
In this research, piercings were directly associ-
ated with adolescence, since all insertions occurred
prior to university admission. Adolescence is a stage
of human development, which includes biological,
psychological and social changes.1,3 The insertion of
such embellishments at this stage can be seen as a rite
of passage, a style, an ideology or a form of expres-
sion, with different understandings and interpreta-
tions according to the literature.9-12,15,31
Embellishments and body alterations are pres-
ent throughout the history of mankind and there are
several reasons for their practice in the contemporary
world.1,18 Among the main reasons to wear this acces-
sory are the expression of identity, followed by beau-
ty and fashion.1,11-13,18 In this study, we found that the
insertion of piercing was influenced by fashion trends
and the search for individual and collective affirma-
tion. The need for experimentation, as well as social
factors encouraging embellishment and consumption
may favor the decision to wear piercings, further
fueled by the industry and trade of body products.
GRAPH 1: Relative frequencies (FR%) of cutaneous lesions seconda-
ry to piercing wear in the first six months after the insertion
Infections Pain/edema/ Hypertrophic
GRAPH 2: Mean duration of lesions secondary to piercing insertion
in different body regions
Ear Ear and Navel Navel Other
Duration of lesion (months)
Variable Category Ear Ear and navel Navel Other p
(n=16) (n=6) (n=29) (n=7)
Secondary lesion Allergy 2 12.5% 0 0% 2 13.3% 0 0% 0.627
Hypertrophic scar 2 12.5% 2 40% 4 26.7% 2 66.7% 0.53
Pain 3 18.8% 2 40% 4 26.7% 2 66.7% 0.63
Edema 3 18.8% 2 40% 4 26.7% 2 66.7% 0.639
Infection 3 18.8% 2 40% 9 60% 2 66.7% 0.825
Bleeding 1 6.3% 0 0% 0 0% 0 0% 0.445
Contact dermatitis 2 12.5% 0 0% 2 6.9% 0 0% 0.627
Unsightly scar 2 12.5% 2 33.3% 7 24.1% 1 14.3% 0.654
TABLE 3: Absolute (FA) and relative frequencies (FR%) of variables related to piercing insertion in different body parts
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An Bras Dermatol. 2014;89(6):905-910.
Piercings in medical students and their effects on the skin 909
In the present investigation, there was a preva-
lence of 58 (36%) piercing wearers among 161 students
that were approached. This result differs from the
studies performed with Portuguese (18%),
Venezuelan (28%) and American (51%) students,
which can be attributed to methodological, demo-
graphic and sociocultural variations.2,6,19 Only the
Portuguese study matched the characteristics of the
sample described here.19
The largest proportion of piercings among
females, although consistent with the literature1, can
be related in our research to the growing presence of
women in medical courses and the social expectation
on the maintenance of aesthetics and beauty stan-
dards12. The quantity of one to two perforations and
the preference for metal adornments was similar to
findings by other authors.1,6,16
The most widely used anatomical site for pierc-
ing insertion in the studies with Portuguese and
Venezuelan medical students was the pinna, whereas
in the present study, the navel region predominated.6,19
A likely explanation is the peculiarity of the Brazilian
social relations, which are expressed through the body
and physical appearance. Another reason is the
opportunity to show or conceal the existing embellish-
ment in the abdomen. The choice of the navel as a
location can still suggest the appraisal for a well-
formed and sensuous female figure.
Studies consider piercings as possible indica-
tors of situations involving smoking, alcohol and drug
abuse.7,11,12 In this study, daily smoking was observed
in three women and three men, with durations rang-
ing from 1-12 years. Two (33%) of these six students
had skin lesions secondary to the piercing insertion,
probably by the action of nicotine on the healing
process, in addition to constitutional factors.
Educational actions on protection and resilience were
suggested to prevent these young people to maintain
or initiate the smoking habit during university.
A research conducted on the detection of drug
abuse among Brazilian medical students indicated the
need to take preventive measures.34 In this study, we
did not specifically address the issue of alcohol and
illegal drugs, however, the tendency to over-medica-
tion verified among the students drew our attention.
On the one hand, the rational use of medications dur-
ing the medical training years can assist in the proper
management of patients afterwards, when these stu-
dents are practicing their profession. However, envi-
ronmental contamination with medication waste and
abuse of psychoactive drugs, are considered problems
of great magnitude nowadays.34
The priorities, in programs of integral attention to
youth and adolescents, are health promotion and dis-
ease prevention to minimize future consequences.1,19,32
Although wearing piercing is a personal choice, exag-
gerated body modifications should be observed with
caution, so that one can differentiate an identity crisis or
fashion fad from psychoaffective disorders.7,8,12,31 These
situations require ethical and sensible approaches, dis-
sociated from discriminatory perceptions, and aimed at
reinforcing dialogue and consolidating trust bonds.1
The lack of straightforward and specific
instructions on the risks of piercing wear exposes
individuals to the vulnerability of procedures per-
formed by unqualified personnel, which is a global
concern.6,12 Research shows that inadequate sanitation,
poor technique, inappropriate material and insertion
in areas subject to friction favor complications.25,26,29 In
the present study, infection and scarring disorders, as
well as pain and edema were frequent, especially in
individuals with navel piercings, but without statisti-
cally significant differences with other regions (p>
0.05). Such situations are likely to be influenced by the
foreign body presence; length of wound re-epithelial-
ization and friction caused by clothing.
Piercing materials containing nickel or chromi-
um may cause dermatitis by irritation or sensitization.
The individual, who insists on keeping the adornment
even with dermatitis, cannot however foresee the
development of hypersensitivity.35 In this investiga-
tion, a student had allergic sensitization to nickel con-
firmed by patch testing.
Unsightly scars, caused by the piercing procedure
with the purpose of making openings or holes to insert
jewelry in that space, can cause physical, social and psy-
chological discomfort.1,14 In this study, we observed that,
in twelve students (20.6%) the scarring disorders had
physical, psychosocial and economic consequences.
Since the use of piercing has become increasing-
ly frequent, physicians need to have correct informa-
tion and guidelines so they can warn and instruct
patients and treat conditions and consequences
imposed by bodily adornments. It is essential to have
the proper training to correct unsightly scars when the
patient wants to remove unwanted marks, as well as
dexterity to remove piercings, particularly intra-and
perioral, in case of complications and emergencies
such as traumas.1,18 By following the technical norms
of safe surgical practice standards, it is possible to pre-
vent potential exposure to contamination by secre-
tions or accidents related to the application of electro-
surgery in patients carrying metal objects.1,14
Notwithstanding the limitations of this study
regarding its design and sample size, this research
emphasizes the need to better educate the public, espe-
cially medical students, about the complications sec-
ondary to piercing wear.19,24,25 The importance of this
Revista6Vol89ingles_Layout 1 9/19/14 7:33 PM Página 909
work lies in finding that the decision to insert the
piercing occurred most often in an uninformed way, by
minors, without seeking medical guidance or parental
consent. Another important fact to stress is that this
type of procedure is not harmless, since it produces
local and systemic unwanted effects, as well as eco-
nomic and emotional costs. Preventive measures must
be known, understood and practiced systematically by
the subject and by all professionals involved before,
during and after the piercing insertion.
Facing all the potential problems that can be
generated by piercing wear, further investigations
with a larger number of participants and a control
group matched by gender and age, can provide infor-
mation to health professionals, parents, educators and
legislators to prioritize preventive measures and
improve the quality of care and conduct.
The prevalence of body piercing among these
medical students was high, especially in females.
Local complications were frequent and predominated
in the first six months after the procedure, especially
in those students with navel piercings. Infectious and
inflammatory processes marked the acute reactions,
while chronic reactions were related to scarring disor-
ders and contact dermatitis.q
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Kátia Sheylla Malta Purim
Universidade Positivo - Curso de Medicina
Rua Professor Pedro Viriato Parigot de Souza, 5300
81280-330 - Curitiba -PR
How to cite this article: Purim KSM, Rosario BA, Rosario CS, Guimarães ATB. Piercings in medical students and
their effects on the skin. An Bras Dermatol. 2014;89(6):905-10.
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