Body decoration in adolescence: tattoos and piercings in individuals with diabetes.

Virginija Bulikaitė

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

Introduction

Tattooing, scarring, and jewelry piercing in various body parts constitute a widespread form of body art globally (1). Individuals, both healthy and those with chronic diseases like Diabetes Mellitus (DM) (2), seek this mode of expressing individuality. According to the World Health Organization, DM is a chronic condition caused by various hereditary and acquired factors, disrupting metabolism through changes in insulin production, secretion, and its effects (insulin resistance), leading to overall metabolic dysfunction involving carbohydrates, proteins, and fats. This condition results in chronic hyperglycemia and can cause long-term damage or dysfunction of several organs, particularly the eyes, kidneys, nerves, heart, and blood vessels (3).

Two decades ago, scientific literature often forbade individuals with DM from tattooing or piercing their bodies, but people frequently ignored these prohibitions, resulting in complications such as infection and ketoacidosis. Recommendations now suggest that individuals with DM who choose to undergo tattooing or piercing can achieve better outcomes than under strict prohibitions (4). A decade ago, healthcare professionals rarely broached this subject with adolescents with DM and their parents. In Lithuania, a specific guide for adolescents with DM was only published in 2017, which includes information on topics like tattooing and piercing (5).

Data on the prevalence of body modifications among adolescents with DM are limited, but their behavior, influenced by psychosocial factors, often mirrors that of healthy individuals (6).

Prevalence of Body Modification

Tattooing and wearing earrings for adornment purposes among adults and children began as early as the Stone Age. Tribal tattoos and jewelry often indicated a person's status, played a role in protection and amulets (7). Later, tattoos were used to mark slaves, criminals, prostitutes, soldiers, war prisoners in concentration camps, and were popular among sailors and nobles in the United States and England. Over the past 10 years, body tattooing has become a universally accepted phenomenon. Today, tattoos are not only popular among representatives of the criminal world, bikers, musicians, athletes, actors, or social media stars. About 30% of Americans and 100 million Europeans have at least one tattoo (1, 6, 7). Tattooing and piercing in various body parts are most common among the 18-29 age group. Interest in body modification starts quite early: cases of tattooing in 8-year-old children have been recorded in the USA (8), and about 23% of individuals aged 12-22 had tattoos, and about 42% had body piercings (excluding earrings in the earlobes) (9).

Age Restrictions

In many developed countries, laws prohibit tattooing the skin or piercing jewelry on minors without parental consent. However, there are regions that ban such interventions even with parental consent (e.g., Wales) or that do not restrict minors' decision-making at all (e.g., the state of Nevada) (2). In Lithuania, tattoos and piercings are done on minors only with the consent of parents or guardians. Lithuanian hygiene standard HN 117:2007 Beauty Service Health Safety Requirements prohibit providing tattooing, permanent makeup, and piercing services to individuals under 18 years of age without written consent from parents or guardians (10).

Understanding Motivation

When a minor decides to get a tattoo, especially in a visible location, or pierces jewelry (excluding earrings in the ears), parents should understand their motives. The entire family can benefit from consulting with a doctor and psychologist (2). Friends might influence body modification decisions, or it may be a way for the minor to attract attention from parents or peers without considering health consequences. In some cases, it may even be an expression of self-harm (6).

Considering Long-Term Effects

Young people need to take their time and understand that a tattoo design will last a lifetime. Over time, they may no longer like it, and it could interfere with their personal life or career (2). Jewelry in visible places like the lip, nose, cheeks, or eyebrow might also become undesirable or bothersome later, leaving holes or scars when removed.

Parental Influence and Professional Guidance

Some parents choose to pierce earrings for babies or young children themselves (6). Discussions with a psychologist or doctor can help adolescents and parents understand future perspectives better. Sometimes, these conversations lead to a decision to abandon or postpone the idea of body modification.

Evaluation of HbA1c Indicator

The doctor should evaluate the HbA1c indicator to understand the average blood glucose concentration of a patient with CD over the past few weeks (11). If several recent HbA1c tests meet the normal range (≤7%), wearing jewelry or getting a tattoo is possible. When the last few HbA1c indicators were higher than 8% or if the CD patient has been diagnosed with heart disease, late CD complications (neuropathy, nephropathy, circulatory disorders), tattooing can pose a health risk. With an elevated HbA1c indicator, pierced or tattooed skin may not heal quickly, often becoming a focus of infection, and may even lead to gangrene (2, 11). A patient's HbA1c exceeding the norm does not mean that they can never safely get a tattoo or wear earrings. It simply requires more attention to controlling blood glucose levels and waiting for the HbA1c indicator to reach normal levels (for some patients, the desire to have a tattoo or wear jewelry motivates better disease control).

Choosing a Tattoo Location

Consulting a Doctor

When dealing with CD, it is essential to discuss the future tattoo location with a doctor. Avoid planning tattoos in areas where insulin injections or blood glucose sensor usage occur, such as the lower back, abdomen, front middle third of the thighs, and upper outer quarter of the buttocks (5). Tattooing in these areas is not recommended for those who need insulin injections there.

Choosing Appropriate Tattoo Locations

Hands and feet are the most commonly tattooed body parts, but in the presence of late CD complications like neuropathy or angiopathy, blood circulation in the limbs may be poor (4). Consequently, feet, ankles, calves, and forearms are not ideal tattoo locations, as they may not heal quickly or may have a higher risk of infection during the healing process.

Avoiding Certain Areas

Avoid tattooing areas with scars or those affected by juvenile acne (12). Selecting an appropriate location can help ensure a safer and more successful healing process.

Informative Tattoo about CD Diagnosis

Informative Tattoos for Diabetes

Sometimes people with CD choose a tattoo that informs about the disease, such as the word "diabetes," the letters "DIA," or symbols related to CD (e.g., a blue circle symbolizing unity in the fight against CD, the insulin formula, or a snake entwined around Asklepios' staff) (13). People often place these tattoos on the right wrist, neck, next to the carotid artery, or on the left side of the chest above the heart to alert the public and medical professionals in case of a hypoglycemic attack.

Effectiveness and Recognition Challenges

Although such tattoos could save time in identifying the disease in critical situations, those providing assistance may not necessarily look for a tattoo or trust it if found. The public might not understand the meaning of the tattoo due to the lack of regulated standards, so individuals with the disease choose a symbol or inscription at their discretion (14).

Alternatives and Considerations

In some countries, adolescents are allowed to get such a tattoo even without parental consent. However, equally effective non-invasive methods include identification bracelets, pendants, cards, inscriptions on shirts, or verbal information to surrounding people about CD (13). Before getting an informative tattoo, evaluate the risk and the individual's health condition.

Choosing a Tattoo and Body Piercing Salon

Before a person with CD chooses a tattoo or body piercing salon, it is recommended to inquire about the artist's license, reviews, assess hygiene conditions (cleanliness of the environment, working with gloves, use of disposable tools, sterilization of reusable tools, disposal of dye residues rather than reuse on another client). A tattoo artist is an artist, not a medical professional. Like a specialist in body piercings, they have knowledge of asepsis and antiseptics, but they do not delve into the health effects of tattooing (8). Once a reliable artist is chosen, it is essential to inform them about the CD diagnosis. In Scotland, 87.5% of body piercing salons would refuse to pierce jewelry for a person with CD (12).

Preparing for a Tattoo or Body Piercing Procedure

Preventing Hypoglycemia

To avoid hypoglycemia (low blood glucose levels), eat at least 1 hour before the procedure (5). Bring essential items such as a blood glucose meter, insulin, water, and carbohydrate-containing foods like juices, glucose tablets, candies, or fruits to prevent hypoglycemia.

Managing Stress and Hyperglycemia

Stress often accompanies such procedures, leading to hyperglycemia (increased blood glucose levels) (15). Measure blood glucose levels, and administer insulin if levels are elevated.

Procedure Duration and Preparation

While wearing jewelry typically does not take long, tattooing is a lengthy process. Determine how long the procedure will take, as you may need breaks for measuring blood glucose levels, consuming carbohydrates, or administering insulin. Attend these procedures with a close companion rather than going alone.

Postpone if Necessary

A concomitant illness (e.g., a cold) or poor blood glucose control before tattooing or wearing jewelry increases the risk of complications. Postpone the procedure in such cases (5).

Monitoring During Healing

Purchase strips for measuring ketones (in blood or urine), as these are not reimbursed for people with CD in Lithuania. Replenish stocks of diagnostic strips for measuring blood glucose levels, as careful monitoring of these indicators is essential throughout the wound healing period after the procedure (15).

Tattoo Healing and Care

After getting a tattoo, it is important to protect against infection and maintain normal blood glucose levels while the skin in the tattoo area heals (5). There should be no problems in treating the tattoo if it 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 deeper layers of the skin heal within up to 4 weeks. Healing takes longer in the case 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 start.
• Third stage (15-30 days): Although the skin appears healed, the deeper layers are still in the healing process (4).

Complications After Tattooing

Tattoo Removal

Healing and Care of Wounds from Piercing

Healing of wounds caused by different body piercings occurs 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 in 4–8 weeks, the nose in 3–6 months, eyebrows and lips in 2–4 months, the belly button, like the ear cartilage, heals in 3–6 months, and female genital piercings take up to 6 months (15). The piercer should provide written care instructions for the wound (specifying which disinfectant solution to use and how many times a day to disinfect the skin). Out of 374 survey participants, 10% regretted getting piercings (excluding earrings in the ears) (2).

Complications of Body Piercings

Complications of Piercing

Piercing commonly leads to local bacterial or viral infections (15). It can also cause mechanical tissue tearing, bleeding, scar formation, and potential damage to facial, trigeminal, glossopharyngeal, or lingual nerves (2). Lip or tongue piercings may damage teeth and gums, while pain and swelling can make eating and drinking difficult for several weeks. Less frequently, systemic infectious diseases like endocarditis, sepsis, hepatitis B, hepatitis C, or HIV can develop.

Infection Management and Monitoring

If the piercing site becomes red, swollen, hot, painful, or starts oozing, monitor blood glucose and ketone levels more frequently (in blood or urine). Infections often require the removal of the piercing to facilitate treatment and prevent scarring (1, 2). If blood glucose levels remain unregulated, consult a doctor immediately. The presence of ketones, nausea, and vomiting are signs of diabetic ketoacidosis, which requires urgent medical assistance for individuals with diabetes (15).

Society's View on Body Adornments

Although it is still believed that tattooed individuals are more prone to risky behaviors (alcohol, drug use, violence, eating disorders, self-harm, suicide), society's attitude towards body adornment is gradually changing. Between 2008 and 2012, the percentage of negative opinions about body tattoos decreased by 24% (2, 6). Attitudes differ among older people, young adults, and children. 64% of older Americans (over 65 years old) had a negative view of body adornments, while 56% of those under 50 had the opposite view. Most young children in the experiment described a tattooed person negatively when seeing images of individuals with and without tattoos. In 2014, a survey of nearly 2,700 people revealed that 76% believed that tattoos and visible piercings (excluding earrings in earlobes) reduce job opportunities. Even 33% of adult Americans regretted getting a tattoo when they were minors (20, 21).

Future Technologies: Smart Tattoos

Scientists are developing tattoo ink that can react to human interstitial fluid, warning of changes in health status. As blood glucose levels or acid-base balance change, the color of the tattoo would also change (22). Another product in development, symbolically called a smart tattoo, applies to the skin (resembling a temporary tattoo) and helps assess blood glucose levels(23).

Summary

For an adolescent with diabetes deciding to get a piercing or tattoo, seeking advice from a doctor and psychologist (involving parents or guardians) helps understand the motives, consequences, and discuss the prevention of possible complications.

References

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5. Guide for adolescents with diabetes. https://www.vgtulicejus.lt/wp-content/uploads/2018/10/2017-Teenager-book-final-LR.pdf.
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