GUIDELINES FOR BODY PIERCING GOOD PRACTICE

DEFINITION Body piercing is the practice of piercing parts of the human body into which jewellery is then inserted. INTRODUCTION These guidelines are aimed at minimising the main dangers associated with body piercing, Hepatitis B and C, HIV transmission, bacterial sepsis, organ or tissue dysfunction and subsequent scarring. THE LAW The Local Government (Miscellaneous Provisions) Act 1982 This requires that persons carrying out ear piercing and the premises where this takes place must be registered with the local authority, and the person and the premises must comply with any bye-laws in force under that Act. If you do not pierce ears then no such registration is required. The Health and Safety at Work etc Act 1974 This act regulates the health and safety of persons at work, including the self employed, and persons affected by a work activity. The Health Protection Unit of the Environment and Health Service enforce the above two Acts in all skin piercing premises within the Borough. The Prohibition of Female Circumcision Act 1985 This Act states that a person who excises, infibulates or otherwise mutilates the whole or any part of the Labia majora, Labia minora or Clitoris of another person is guilty of a criminal offence. Therefore piecing the female genitalia could be an offence and this must be considered before such piercing are performed. It is important to note that the Act does not allow females to consent to any procedure that could be defined as female circumcision. Age of Person Requesting Piercing There is no specific legislation covering this aspect. However any piercing of male or female genital organs, including breasts, carried out on a child under the age of 16 years would be regarded as indecent assault because children of that age cannot give consent to such activities. Where piercing is not prohibited by the above legislation it is in any case recommended that parental consent be obtained in writing in the case of

persons under the age of 18 years. Proof of age should be sought if there is any uncertainty. It is also important to note the words of Judge Rant QC in the case of Oversby, piercing parts of the anatomy other than the ears is lawful, provided that the piercing is carried out for decorative or cosmetic purposes and not for sexual gratification. Finally it is recommended that clients be encouraged to bring a friend for moral support to prevent misunderstandings or allegations of impropriety, especially in the case of genital piercing. THE PIERCER Body piercing must only be carried out by people who have received suitable training and supervision and are competent in both the technical and the manual skills necessary to perform a piercing that will not cause infection, unnecessary scarring or bodily dysfunction. There are currently no recognised qualifications. It may therefore be necessary for inspecting officers to ask questions that will reveal the piercers level of knowledge about the hazards of body piercing and how to avoid them. The piercer should be vaccinated against Hepatitis B virus and it is recommended that piercers hold an HSE approved Basic First Aid qualification. When piercing the piercer should avoid open footwear and bare legs to reduce the risk of needlestick injury. Piercers must not be under the influence of drugs, alcohol or other substances. THE PREMISES Body piercing must be carried out in an area separated from other activities and in circumstances where privacy can be assured. The piercing area should be well illuminated, have suitable and sufficient heating and ventilation and be large enough to provide adequate space for the piercing activities to be performed safely and efficiently. There should be a notice prominently displayed informing potential clients of the risks associated with body piercing; Blood poisoning (septicaemia) Localised severe swelling and trauma around the piercing site. Localised infection, e.g. sepsis or arthritis. Scarring. Jewellery embedding. Allergic reaction to jewellery materials and antiseptics. The client should be provided with a couch or similar item to enable them to be pierced in a reclined position to minimise the consequences of fainting.

NB. This is not appropriate for tongue piercing due to the risk of inhaling or swallowing the jewellery. The couch must be covered with a clean disposable paper sheet for each client. All surfaces must be clean and capable of being readily cleansed and disinfected. There must be suitable hand washing facilities with hot and cold running water together with soap and paper towels or other suitable means of hand drying. There must be suitable equipment washing facilities with hot and cold running water. Equipment cleaning is best carried out by the use of an Ultrasonic cleaner used in accordance with the manufacturers instructions. Where equipment is cleaned in a sink only tepid water should be used and the operator must wear latex gloves and suitable eye protection due to the risk of viral particle splashes. The clean and dirty areas must be separate and the flow of operations should ensure that cross contamination does not occur. A suitable First Aid kit must be readily available. Copies of the guidance produced should be freely available in the waiting area. PRE-PIERCING CONSENT The piercer must discuss the clients medical history and in particular ask whether they have suffered from any of the following; Heart Disease Haemorrhagic (bleeding) disorders including leukaemia Seizures e.g. Epilepsy Diabetes, Aids, Psoriasis, Cellulitis Allergic responses e.g. anaesthetics, adhesive plasters, jewellery metals Genital warts - if relevant to the piecing requested and fainting. and if they are currently on any medication or under the influence of alcohol, drugs or other substances or are obviously unwell. Piercing should not be performed on skin that is diseased or affected by a rash or moles. Where any of the above conditions exist, or there is a past history, written authorisation from the clients GP should be required. A written record must be made of the clients personal details to include; Name, Address, Date of Birth Details of previous piercings Relevant medical information as specified above. Copy of GPs letter if appropriate.

The client should be required to complete a Skin Piercing Consent Form See Appendix 1. The above records should be kept on the premises for a period of at least three years. BODY PIERCING PROCEDURE AND EQUIPMENT It is essential that body piercers have a clear understanding of good practice and that they put this into good effect. In order to achieve this and also to comply with the various requirements under the Health and Safety at Work etc Act 1974 and regulations made thereunder, it is necessary for a written method statement to be prepared. This method statement must identify the various stages in the piercings undertaken and the methods used to ensure safety and efficient piercing. In particular the following points will need to be included with details of the procedures to be adopted. There must be no smoking or eating in the piercing room. Once the client has been interviewed and their medical status established the jewellery can be chosen for the desired effect. All jewellery must be of a suitable grade e.g. surgical stainless steel, solid 14K or 18K gold, niobium, titanium, platinum, or dense low porosity plastic. The client will wish to see the choice of jewellery on offer and probably will want to handle it. It is therefore suggested that a full range of the jewellery be available for clients to examine separate from the jewellery that will be used in the piercing because that must be clean and sterile. Many clients may wish to be anaesthetised at the site of the piercing. However the use of anaesthetic injections is restricted by the Medicines Act 1968 to doctors, nurses and veterinary surgeons. The use of surface local anaesthetics is not recommended. a) Ethyl Chloride - This is very flammable, non-sterile, may cause an allergic reaction, is not always effective and can cause frostbite. b) Cream preparations - these are usually only available on prescription and can take 30-60 minutes to act. They may also cause side effects. Prior to piercing the operator must surgical scrub with a suitable bactericidal soap and hot water (nails, hands and up to elbows) dry with disposable paper

towels, or other approved method of drying, and then wear new disposable gloves for each client. If the piercing site is to be marked then this should be done with a fine indelible pen, preferably gentian violet, prior to cleaning the piercing site. The piercing site must be cleaned with a disposable single use alcohol based swab. The only exceptions to this are the inner mucosal lining of the nose, which cannot be swabbed effectively, and the tongue. In the case of tongue piercings the mouth must be vigorously swilled with a suitable antiseptic mouthwash. Piercing should not take place into a muscle, artery, vein, nerve or other potentially hazardous site. All piercing needles must be new pre-packed, pre-sterilised needles. Hollow piercing needles should be a minimum of 1.55mm in diameter and no more than 2.5mm to reduce healing complications. The needle should be the same diameter as the jewellery to be inserted. Piercers must be aware of the risks involved in the incorrect or prolonged use of forceps. All surgical instruments in the piercing, e.g. forceps, and all jewellery must be sterile at the start of the piercing. Sterilisation of equipment must be carried out using an autoclave or bench top steam steriliser. Only sterilisers marked CE or in compliance with BS.3970 part 4: 1990 are considered acceptable at present. No envelopes, pouches or wrappings of any kind may be used in bench top steam sterilisers. These sterilisers must also not be used to sterilise hollow needles or any equipment with hollow parts because the steam will not penetrate effectively. Autoclaves and bench top steam sterilisers must be serviced and calibrated at least annually and when used must be operated in accordance with the manufacturers instructions. A guide to the performance can be obtained by the use of colour change papers that are placed in the machine for each cycle. These must be used to check for failure to operate effectively. The only type of autoclave suitable for needles, pouches etc is one that includes a vacuum cycle in the sterilisation programme. Specification and details of testing and maintenance are available in a booklet about the purchase, operation and maintenance of bench top steam sterilisers This is available from:

The Medical Devices Agency Ordering Department Room 1207 Hannibal House Elephant & Castle London SE1 6TQ It is worthy of note that the organism responsible for the transmission of Creutzfeld Jacob Disease (CJD) cannot be destroyed by sterilisation in an autoclave. In the event that a client is known to have this disorder all equipment in contact with that persons bodily fluids must be disposed of. All jewellery and equipment that has been sterilised must be stored in such a manner as to prevent contamination that could give rise to infection. A No Touch technique, e.g. using forceps, should be used to reduce the risk of infection and injury to the piercer. The needle should be held away from the tip. Once the needle has pierced the flesh the jewellery should be inserted by the following needle. It is permissible to lubricate the jewellery with a small amount of Savlon cream. Any cream used, e.g. anaesthetic cream or Savlon, must be dispensed onto sterile gauze first and any surplus disposed of with the gauze. Nose piercing is not recommended because the inner muscosal surface cannot be adequately disinfected and may contain pathogenic organisms. There is also a risk of disfigurement if infection occurs. The guns designed for ear piercing must not be used for other piercings especially the nose. This is because the guns will become contaminated and could subsequently be the vehicle of infection to other clients. Only the completely disposable ear piercing systems should be used. There are currently the COREN, MEDISEPT, BLOMDAHL and STUDEX types, but only with the back clasp removed. Only experienced operators should pierce the head of the penis (glans) because such piercings can cause scarring and problems with the flow of urine. Worktops and surfaces generally should be cleaned regularly using a detergent solution unless there is visible contamination with bodily fluids. In this case the surface should be cleaned and disinfected with a solution containing 10,000ppm available chlorine. POST PIERCING AFTER CARE

Clients need to be given detailed written guidance regarding after care because it is during the healing period that most infections can occur and serious consequences could result. Suggested information may be found in Appendix 1.

SKIN PIERCING CONSENT FORM

To be filled in clearly and correctly by persons wishing to be pierced NAME : ADDRESS : . .. TELEPHONE : AGE : .. This is to certify that I, the above named and undersigned, today gave my correct name, address and age when asked to do so by ADDRESS OF SKIN PIERCING ESTABLISHMENT

This is to certify that I, the undersigned, do give my permission to be pierced and am fully aware of the process involved and understand the importance of the daily aftercare procedure. SIGNED : DATE : Where the client is under the age of 18 the parent or guardian must also sign. SIGNED : DATE : TYPE OF PIERCING :

APPENDIX 1

AFTER CARE GUIDELINES FOR SKIN PIERCING

Clients are advised to follow the simple after care procedure outlined below; A Normal Piercing:

May be tender, itchy, slightly red or bruised for a few weeks. May bleed a little for the first few days. May secrete a whitish-yellow fluid (plasma) which crusts on the jewellery, this is not pus. May tighten around the jewellery as it heals, making turning difficult.

Cleaning/Healing process: It is important to keep the piercing site clean and dry and undisturbed. Clean the piercing no more than is necessary to maintain cleanliness. Frequent cleaning may damage the delicate skin cells. If cleaning of the pierce becomes necessary then always wash hands well and dry thoroughly with a clean towel and then keep the site dry and clean. With an oral piercing, after eating, smoking or putting anything in the mouth, rinse with antibacterial mouthwash at a dilution of 50%-75% to avoid damaging new skin cells. It is also necessary to disinfect the piercing twice a day with warm salt water or a mild antiseptic mouthwash. Hot soaks and compresses with the optional addition of teaspoon of sea salt per cup of clean water are strongly suggested for navel piercings. Avoid wearing belts, tight trousers or restrictive clothing for about 6-12 months. Genital piercings (male/female) can use a panty liner to absorb excess moisture and cushion the piercing. Avoid restrictive clothing, irritating clothing or clothing that limits oxygen flow to the area. Any sexual contact should be gentle and latex barriers should be used to protect the piercing from partners body fluids.

Changing and Removing Jewellery: Everyone heals at a different rate. The average healing times for piercings, provided they are cleaned twice daily and treated like new healing tissue, are shown below. It is important to remember that even after the initial healing period, the piercing will still need one full year or longer to completely heal. Always treat the piercing with care and gentleness. Ears: 2-3 months Lip, Labret: 6-8 weeks Tongue: 4-6 weeks Cheek: 2-3 months Navel: 6 months to 2 years Nipple: 2-6 months Genital piercings: 4-8 weeks

Jewellery should not be changed during the initial healing period (often at least 6 months). Clients should be advised to always wear the appropriate jewellery in the piercing even when fully healed. The piercer should be contacted, for further advice, if removal of the jewellery is being considered on a temporary or permanent basis. There must not be an attempt to increase the size of the piercing until it is completely healed. Such increasing should be carried out gradually by the insertion of progressively larger gauge sterile jewellery. No subsequent tearing or bleeding should occur. What to do in case of infection: Infections are caused by contact with bacteria, fungi or other living pathogens. Piercing infections can usually be traced to one of the following activities; Touching the piercing with unwashed hands Oral contact with the piercing, including your own saliva Contact with hair, cosmetics, oils, infrequently washed bedding or other agents. Going into a pool, hot tub, lake, ocean or other body of water

The following are indications of infection: Redness and swelling. A sensation of heat at the piercing site Pain, especially throbbing or spreading pain Unusual discharge. It may be yellowish, greenish or greyish

While it is never inappropriate to contact the doctor, a visit to the piercer may be as beneficial. Do not remove the jewellery as this may aggravate the problem by

losing off the drainage for the discharge matter. You might consult the doctor regarding the use of oral antibiotics. Common Problems that can be Avoided: Over cleaning, vigorous cleaning, or using a cleanser that is too strong can produce symptoms very similar to an infection. The skin may be very tender and appear shiny and there may be a clear discharge. Friction caused by tight or heavy clothing, rough sexual activity, or excessive movement of the area can cause dark redness, a hard growth of skin over the scar (keloids) discharge and rejection/migration. Stress, poor diet or illness can cause longer healing times or migration of the piercing. Occasionally the selected jewellery may not be appropriate. This may or may not be due to circumstances that occurred after the piercing. If the jewellery is too thin or too heavy, too large or too small in diameter or not the appropriate style, healing problems may be experienced. The piercer should be contacted if a change in jewellery is required.

These guidelines have been drawn up using information from many sources including the following; Professor Norman Noah Communicable Disease Surveillance Centre 61 Colindale Avenue LONDON NW9 5EQ Communicable Disease Control Southampton and South West Hampshire Health Authority Inspector L.W. Laws Divisional Youth Care Officer and Prosecution Inspector Hampshire Constabulary Mr. Paul Bandy A representative of the London Special Treatments Working Group on Body Piercing

Thanks must be given for their assistance and valuable guidance.