Body Decoration in Adolescence: Tattoos and Piercings in Young People With Diabetes

Virginija Bulikaitė

Department of Nursing and Care, Medical Academy, Lithuanian University of Health Sciences
Endocrinology Clinic, Kaunas Clinics, Lithuanian University of Health Sciences

Introduction

Tattooing, scarification, and body piercing are widespread forms of body art worldwide (1). Both healthy individuals and those with chronic diseases, including diabetes mellitus (DM), use these forms of body modification to express their individuality (2). The World Health Organization defines DM as a chronic disease caused by various hereditary and acquired factors that disrupt metabolism due to changes in insulin production, secretion, and action (insulin resistance), or a combination of these mechanisms, resulting in disturbances of carbohydrate, protein, and fat metabolism, chronic hyperglycemia, and long-term damage or dysfunction of several organs, particularly the eyes, kidneys, nerves, heart, and blood vessels (3).

Two decades ago, the scientific literature advised individuals with DM against tattooing or body piercing. However, these recommendations were often disregarded, sometimes resulting in complications such as infection and ketoacidosis. Providing recommendations for individuals with DM who decide to get a tattoo or piercing has produced better results than imposing prohibitions (4). Ten to fifteen years ago, healthcare professionals rarely discussed this topic with adolescents with DM and their parents. In Lithuania, a guide specifically intended for adolescents with DM was published only in 2017 and includes information about tattooing and piercing, among other relevant topics (5). There are limited data on the prevalence of these forms of body modification among adolescents with DM; however, their behavior, influenced by the same psychosocial factors, does not differ from that of healthy individuals (6).

Prevalence of Body Modification

Tattooing and wearing jewelry for decorative purposes among adults and children date back to the Stone Age. Tribal tattoos and jewelry often indicated a person's status and served protective or amuletic purposes (7). Later, tattoos were used to mark slaves, criminals, prostitutes, soldiers, and prisoners of war in concentration camps and were also popular among sailors and members of the nobility in the United States and England.

Over the past 10 years, body tattooing has become a widely accepted phenomenon. Today, tattoos are no longer popular only among members of the criminal world, bikers, musicians, athletes, actors, or social media stars. Approximately 30% of Americans and 100 million Europeans have at least one tattoo (1, 6, 7). Tattooing and body piercing are most common among individuals aged 18–29 years. Interest in body modification begins quite early: cases of tattooing in children as young as 8 years have been reported in the United States (8), while approximately 23% of individuals aged 12–22 years had tattoos and approximately 42% had body piercings, excluding earrings in the earlobes (9).

Age Restrictions

In many developed countries, laws prohibit tattooing or body piercing in minors without parental consent. However, some regions prohibit such procedures even with parental consent, such as Wales, while others impose no restrictions on minors' decision-making, such as the state of Nevada (2). In Lithuania, tattoos and piercings may be performed on minors only with the consent of their parents or guardians. Lithuanian Hygiene Standard HN 117:2007, Health Safety Requirements for Beauty Services, prohibits the provision of tattooing, permanent makeup, and piercing services to individuals under 18 years of age without the written consent of their parents or guardians (10).

Understanding Motivation

When a minor decides to get a tattoo, particularly in a visible area of the body, or a body piercing other than earrings in the ears, parents are advised to understand the reasons behind this decision. It is often useful for the entire family to consult a physician and psychologist (2). Sometimes body modification is a decision influenced by friends; in other cases, it may be a way of attracting the attention of parents or peers without considering the potential health consequences, or it may represent an expression of self-harm (6).

It is important for a young person not to rush into the decision and to understand that a tattoo design will remain for life, may no longer be appealing over time, and may even interfere with personal life or career opportunities (2). Jewelry worn in visible areas, such as the lip, nose, cheeks, or eyebrow, may also become undesirable or bothersome later, and its removal usually leaves holes or scars. There are also cases in which parents themselves want to have the ears of infants or young children pierced (6). After discussions with a psychologist or physician, some adolescents and parents gain a better understanding of the future implications and may decide to abandon the idea or postpone it until a later time.

Evaluation of HbA1c

The physician should evaluate the HbA1c level to assess the average blood glucose concentration of a patient with DM over the preceding several weeks (11). If several recent HbA1c measurements have been within the normal range (≤7%), getting a tattoo or wearing body jewelry is possible. If the most recent HbA1c values have been above 8%, or if the patient with DM has been diagnosed with heart disease or late complications of DM, such as neuropathy, nephropathy, or circulatory disorders, tattooing may pose a health risk.

When HbA1c is elevated, pierced or tattooed skin may heal more slowly, frequently become a focus of infection, and may even lead to gangrene (2, 11). An HbA1c level above the normal range does not mean that a patient will never be able to safely get a tattoo or wear body jewelry. It simply requires greater attention to blood glucose control and waiting until the HbA1c level reaches the normal range. For some patients, the desire to get a tattoo or wear body jewelry may motivate them to improve disease control.

Choosing a Tattoo Location

In patients with DM, the intended tattoo location should be discussed with a physician. Tattoos should not be planned in areas used for insulin injections or blood glucose sensors, including the lower back, abdomen, middle third of the anterior thighs, and upper outer quadrant of the buttocks (5). If a tattoo is placed in an area used for insulin administration, insulin injections in that area are not recommended.

The hands and feet are among the most commonly tattooed areas of the body, but in the presence of late complications of DM, such as neuropathy and angiopathy, blood circulation in the extremities may be impaired (4). Therefore, the feet, ankles, calves, and forearms are not ideal locations for tattoos because healing may be slower and the risk of infection during the healing process may be higher. Tattooing should also be avoided in areas with scars or areas affected by juvenile acne (12).

Informative Tattoo About a DM Diagnosis

Sometimes people with DM choose a tattoo that provides information about their condition, such as the word "diabetes," the letters DIA, or symbols associated with DM, for example, a blue circle symbolizing unity in the fight against DM, the insulin formula, or a snake entwined around the staff of Asclepius (13). Such tattoos are often placed on the right wrist, on the neck near the carotid artery, or on the left side of the chest above the heart, with the aim of alerting the public and medical professionals, for example, in the event of a hypoglycemic episode.

Although such a tattoo could save time in identifying the condition in critical situations, those providing assistance may not necessarily look for a tattoo and, even if they notice one, may not necessarily trust it. The meaning of the tattoo may also not be understood by the public because there are no regulated standards, and individuals with the condition choose a symbol or inscription at their own discretion (14). In some countries, adolescents are permitted to obtain such a tattoo even without parental consent. However, equally effective non-invasive alternatives are available, including identification bracelets, pendants, cards, inscriptions on clothing, and verbally informing people around them about DM (13). Before getting an informative tattoo, the potential risks and the individual's health status should be evaluated.

Choosing a Tattoo and Body Piercing Salon

Before a person with DM chooses a tattoo or body piercing salon, it is recommended to inquire about the artist's license and reviews and to assess hygiene conditions, including environmental cleanliness, the use of gloves and disposable instruments, sterilization of reusable instruments, and disposal of residual dye rather than its reuse for another client.

A tattoo artist is an artist, not a medical professional. Like a body piercing specialist, a tattoo artist has knowledge of asepsis and antisepsis but does not extensively assess the health effects of tattooing (8). Once a reliable artist has been selected, it is essential to inform them about the DM diagnosis. In Scotland, 87.5% of body piercing salons would refuse to perform a piercing on a person with DM (12).

Preparing for a Tattoo or Body Piercing Procedure

To avoid hypoglycemia, or low blood glucose levels, it is recommended to eat at least 1 hour before the procedure (5). It is necessary to have a blood glucose meter, insulin, water, and carbohydrate-containing foods for the prevention of hypoglycemia, such as juice, glucose tablets, candy, or fruit.

Stress is commonly experienced before such procedures and may result in hyperglycemia, or elevated blood glucose levels (15). Blood glucose levels should therefore be measured, and if they are elevated, insulin should be administered. Body piercing usually does not take long, whereas tattooing can be a lengthy process. It is recommended to determine in advance how long the procedure will take, as breaks may be needed to measure blood glucose levels, consume carbohydrates, or administer insulin. It is advisable to attend such procedures with a close companion rather than alone.

A concomitant illness, such as a cold, or poor blood glucose control before tattooing or body piercing increases the risk of complications; therefore, the procedure should be postponed in such cases (5). It is recommended to purchase test strips for measuring ketones in the blood or urine, which are not reimbursed for people with DM in Lithuania, and to replenish supplies of blood glucose test strips, as these parameters should be carefully monitored throughout the wound-healing period following the procedure (15).

Tattoo Healing and Care

After getting a tattoo, it is important to prevent infection and maintain normal blood glucose levels while the skin in the tattooed area heals (5). There should be no problems with tattoo healing if the area is properly cared for. The artist should provide clear written instructions on how to care for the tattoo at home. The epidermis heals within 1–2 weeks, while the deeper layers of the skin may take up to 4 weeks to heal. Healing takes longer in the presence of hyperglycemia.

• First stage (1–6 days): skin swelling and redness gradually decrease, and scabs begin to form.
• Second stage (7–14 days): itching and peeling begin.
• Third stage (15–30 days): the skin appears healed, but the deeper layers are still healing (4).

Complications After Tattooing

Tattoo ink can cause allergic reactions (16). Red pigment causes the most adverse reactions, including allergies and granulomas. Yellow pigment can cause an allergic reaction when exposed to ultraviolet radiation; in sunlight, yellow pigments break down into colorless components, the tattoo fades, and the colorless components produced by degradation may have carcinogenic effects. If the pigment contains iron oxide, a burning sensation and irritation may occur during magnetic resonance imaging.

Tattoo pigments can be detected in lymph nodes as early as 15 minutes after tattooing begins, and the lymph nodes may subsequently enlarge, raising suspicion of infection or even oncological disease (16, 17). Failure by the artist to comply with hygiene standards can lead to local infection, manifested by redness, swelling, and pus formation, and, in rare cases, systemic infection, including hepatitis B, hepatitis C, tetanus, or HIV (18).

If a patient has difficulty regulating blood glucose levels after a tattooing procedure, ketones may develop, potentially leading to ketoacidosis (5). A physician should be consulted in cases of prolonged hyperglycemia, pus formation, fever, or enlarged lymph nodes. In a person with DM, the presence of ketones, nausea, and vomiting requires immediate medical attention (15).

Tattoo Removal

Tattoos can be removed using laser treatment, surgical methods, chemical agents, microdermabrasion, cryotherapy, or by covering an old tattoo with a new one. Tattoo removal is a lengthy, relatively expensive, and painful process, and some pigment dyes containing metal oxides, usually black, red, brown, or white, cannot be removed by laser.

Adolescents often overestimate the effectiveness of tattoo removal. The outcome is not always as expected and may include changes in skin texture, scarring, residual pigment, and other effects (19). One-third of people regret tattoos obtained during adolescence (20), and these are often the tattoos they most want to remove because a design or symbol chosen at an immature age may no longer correspond to their preferences as adults.

Hasty decisions are regretted not only by adults but also by those who have only recently left a tattoo or piercing studio. Of 62 adolescents who obtained a tattoo at 11–14 years of age, 47% regretted their decision. Among 282 adolescents aged 15–19 years who were surveyed, 27% no longer liked their tattoo. Men regret impulsive tattoos more often than women, perhaps because they tend to choose larger tattoos in more visible areas (1). Adolescents should be advised not to rush into tattooing visible parts of the body, such as the face, neck, or wrists, and may initially consider a temporary tattoo, although this can also cause an allergic reaction (2).

Healing and Care of Piercing Wounds

Wounds caused by different types of body piercing heal at different rates. The earlobe heals the fastest, within 4 weeks, while male genital piercings take the longest to heal, up to a year. The tongue heals within 4–8 weeks, the nose within 3–6 months, the eyebrows and lips within 2–4 months, the navel and ear cartilage within 3–6 months, and female genital piercings within up to 6 months (15).

The piercer should provide written instructions for wound care, specifying which disinfectant solution should be used and how many times a day the skin should be disinfected. Of 374 survey participants, 10% regretted having body piercings, excluding earrings in the ears (2).

Complications of Body Piercings

Body piercing most commonly leads to local bacterial or viral infections (15). Mechanical tissue tearing, bleeding, scar formation, and possible damage to the facial, trigeminal, glossopharyngeal, or lingual nerves may also occur (2). Lip or tongue piercings can damage the teeth and gums, while pain and swelling may make eating and drinking difficult for several weeks.

Less commonly, systemic infectious diseases may develop, including endocarditis, sepsis, hepatitis B, hepatitis C, and HIV. If the piercing site becomes infected, with redness, swelling, heat, pain, or discharge, blood glucose and ketone levels in the blood or urine should be monitored more frequently. When an infection develops, the piercing usually needs to be removed; otherwise, the infection may be difficult to treat and may result in scarring (1, 2).

If blood glucose levels cannot be regulated, it is essential to consult a physician. The presence of ketones, nausea, and vomiting are signs of the acute complication diabetic ketoacidosis. In such cases, a person with diabetes requires immediate medical attention (15).

Society's View on Body Adornments

Although tattooed individuals are still believed to be more prone to risky behaviors, including alcohol and drug use, violence, eating disorders, self-harm, and suicide, society's attitudes toward body adornment are gradually changing. Between 2008 and 2012, the proportion of negative opinions about body tattoos decreased by 24% (2, 6).

Attitudes differ among older people, young adults, and children. Among older Americans over 65 years of age, 64% had a negative view of body adornments, while 56% of those under 50 years of age held the opposite view. In an experiment, most young children described a tattooed person negatively when shown images of individuals with and without tattoos. In 2014, a survey of nearly 2,700 people found that 76% believed tattoos and visible piercings, excluding earrings in the earlobes, reduced employment opportunities. As many as 33% of adult Americans regretted having obtained a tattoo while they were minors (20, 21).

Future Technologies: Smart Tattoos

Scientists are developing tattoo inks that can react to human interstitial fluid and provide warnings about changes in health status. As blood glucose levels or acid-base balance change, the color of the tattoo would also change (22). Another product under development, symbolically referred to as a smart tattoo, would be applied to the skin, resembling a temporary tattoo, and would help assess blood glucose levels (23).

Summary

Adolescents with diabetes who decide to get a body piercing or tattoo are advised to consult a physician and psychologist, with the involvement of their parents or guardians, to understand their motivations and potential consequences and to discuss the prevention of possible complications.

References

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