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Ear piercing for individuals with metal hypersensitivity
Ear piercing for individuals with metal hypersensitivity ANTHONY J. CORNETTA, MD, and DAVID REITER, MD, DMD, Philadelphia, Pennsylvania
OBJECTIVE: To describe and evaluate an ear piercing and earring retention method for individuals with metal hypersensitivity. SETTING: Private facial plastic surgery practice associated with a tertiary care medical center. METHODS: Thirty-one patients with a history of hypersensitivity to metallic jewelry (62 ears) underwent earlobe piercing with an intravenous catheter. RESULTS: None of the patients experienced an infection or hypersensitivity reaction. All patients were able to wear nickel-free earrings for short periods without using the shortened catheter. CONCLUSION: Using the distal shaft of an intravenous catheter as an earring post sheath is a safe and effective technique that allows hypersensitive individuals to wear earrings in pierced ears on a limited basis. (Otolaryngol Head Neck Surg 2001;125:93-5.)
T
he majority of the female population wears earrings, usually without incident. Ear piercing, a seemingly innocuous procedure, is actually fraught with complications.1-3 These include allergic dermatitis, infection, inflammation, bleeding, drainage, cysts, and tears. Metallic hypersensitivity causes unsightly and often uncomfortable inflammation in affected areas, making it difficult or impossible for patients to wear earrings. A variety of ear piercing techniques and instruments have been described in the literature. They include the use of an intravenous cannula, a trocar needle, a wire loop, a 30- and 16-gauge needle, magnetic earrings, a modified surgical forceps with needle and anvil, and a spring-loaded piercing gun.4-9 These are all innovative
methods, but the authors fail to relay patient outcome data. To date, only one study has evaluated the results of their technique, which uses an eyelet-type Teflon tube.10 We have devised a slightly different method of ear piercing and earring retention that permits hypersensitive individuals to wear earrings in pierced lobes. METHODS AND MATERIALS Thirty-one patients with a history of hypersensitivity to metallic jewelry (62 ears) underwent earlobe piercing. The anterior and posterior aspect of the earlobe was prepped with isopropyl alcohol. The earring location was marked with a sterile marking pen and then confirmed by the patient with a handheld mirror. One percent lidocaine with 1:100,000 epinephrine was injected with a 27-gauge needle. A 20-gauge intravenous infusion catheter was introduced through the earlobe from the anterior aspect in a slightly downward direction (Fig 1). Once entirely through the lobe, the needle was withdrawn (Fig 2). The catheter was cut to protrude 1 to 2 mm from either surface of the lobe (Fig 3). Patients were offered the option of bringing their own 14K gold (or higher) stud earrings or wearing stainless steel Coren (Hastings Corp, Chicago, IL) studs from office stock for one month. After soaking in isopropyl alcohol for 15 minutes, the chosen earrings were placed through the catheter shafts and their backs snapped into place (Figs 4 and 5). Patients were advised to gently clean the earlobe with soapy water on a daily basis and to abstain from twisting the catheter-shaft-over-earring-stud units. The daily use of antibiotic ointment was encouraged for the first week. The senior author replaced the catheter-stud units after 30 days with Coren stainless steel studs. Patients were given several shortened catheter shafts to use over their earring posts if and when they wanted to wear earrings known to incite a reaction. RESULTS
From the Department of Otolaryngology–Head and Neck Surgery, Jefferson Medical College, Thomas Jefferson University. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Washington, DC, September 24-27, 2000. Reprint requests: Anthony J. Cornetta, MD, Department of OTOHNS, 925 Chestnut Street, Sixth Floor, Philadelphia, PA 19107; email, [email protected]. Copyright © 2001 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/1/116787 doi:10.1067/mhn.2001.116787
All 62 piercings (31 patients) were placed in the soft tissue of the earlobe and not in the auricular cartilage. None of the patients experienced an infection or hypersensitivity reaction. All patients were able to wear nickel-free earrings without using the shortened catheter. Some individuals would occasionally re-insert the catheter to wear earrings known to incite a skin reaction. No lobe developed a cleft, and no patient developed a complication of the procedure or of subsequent 93
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Otolaryngology– Head and Neck Surgery July 2001
Fig 1. A 20-gauge intravenous catheter is introduced into the earlobe from the anterior aspect in a downward direction.
Fig 3. After trimming the catheter, 1 to 2 mm protrudes from either side of the earlobe.
Fig 2. Once through the earlobe, the needle is withdrawn.
Fig 4. An anterior view of the earring stud within the catheter shaft.
earring use. None of the 18 patients still in contact at 2 years reported any complications. DISCUSSION
Metallic hypersensitivity is an irritative condition characterized by redness, itching, induration, and crusting. In the United States, nickel sensitivity is 10 times more common in women than in men, probably because women have greater exposure to jewelry that contains nickel.11,12 Earlobe piercing has been shown to sensitize individuals to certain metals.13 Nakada et al13 demonstrated that significantly more individuals with pierced ears had patch-tested allergies to nickel, gold, and mercury compared with those without piercings. Fischer et al12 demonstrated nickel release from stainless steel, gold, or silver-plated, and even “hypoallergenic” earrings. White gold and yellow gold have been shown to induce contact dermatitis in sensitive individuals.14,15 Three questionnaire studies have revealed that 73% to 93% of the adult female population has at least one ear pierced, and the majority of women without pierc-
ings desire ear piercing.1,2,16 Medical personnel, a relative or friend, or store clerk may perform ear piercing. It has been shown that the complication rate is not correlated with who carries out the piercing.1 Complication rates range from 34% to 52% and include contact dermatitis, inflammation, infection, bleeding, drainage, cysts, and tears.1-3 Allergic reaction and minor infection are the most common complications. Simplot and Hoffman16 demonstrated that piercings through auricular cartilage do not carry a statistically significant increase in the general complication rate when compared with soft tissue piercings. There is a trend, however, toward a higher infection rate when piercing through cartilage. Several cases of Pseudomonal and Staphylococcal perichondritis have been reported.17,18 All 31 patients in this study had previously worn earrings but discontinued use because of metal hypersensitivity. The earring tracts had closed because of the extensive length of time that most had avoided wearing earrings. Each patient agreed to undergo this piercing
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method with the hope of wearing earrings again. Patient selection is important because earlobes scarred by recurrent infections, as well as lobes of less than 4 mm thickness, are more likely to tear.19 None of the earlobes pierced in this study possessed either of these characteristics. The likelihood of earlobe clefting may actually decrease because of the zero incidence of infection with this method. Immediate local care of the pierced sites is also important, possibly affecting outcome. Cleaning the piercing sites with isopropyl alcohol and twisting the earring studs daily lacks any justification.20 This practice may actually thin the developing epithelial lining. CONCLUSION
Our method is safe and quick with no reported complications. Using the distal shaft of an intravenous catheter as an earring post sheath allows hypersensitive individuals to wear earrings in pierced ears on a limited basis. Ideally, this procedure best suits individuals who can wear either gold or stainless steel earrings without the catheter after 1 month. By leaving 1 to 2 mm of shaft covering the earring post beyond each surface of the pierced lobe, the earring ornament and post holder do not have sufficient contact with the lobe skin to provoke a reaction. This allows the patient to occasionally wear an earring containing a known allergenic metal. REFERENCES 1. Biggar RJ, Haughie GE. Medical problems of ear piercing. NY State J Med 1975;75:1460-2. 2. Cortese TA, Dickey RA. Complications of ear piercing. Am Fam Physician 1971;4:66-72. 3. Hendricks WM. Complications of ear piercing: treatment and prevention. Cutis 1991;48:386-94. 4. Zackowski DA. An IV cannula stent for ear piercing [letter]. Plast Reconstr Surg 1987;80:751. 5. Goff WF. Ear piercing: by whom? Eye Ear Nose Throat 1975;54:319. 6. Goldman L, Kitzmiller KW. Earlobe piercing with needles and wires. Arch Dermatol 1965;92:305-6. 7. Landeck A, Newman N, Breadon J, et al. A simple technique for ear piercing. J Am Acad Dermatol 1998;39:795-6. 8. Matarasso SL, Glogau RG. Surgical pearl: ear piercing facilitated by magnetic earrings. J Am Acad Dermatol 1994;31:485-6. 9. Duffy MM. A simple instrument for ear piercing. Plast Reconstr Surg 1967;40:92-3.
Fig 5. A posterior view of the earring stud within the catheter shaft.
10. Inoue T, Kurihara T, Harashina T. Ear-piercing technique by using an eyelet-type Teflon piercer (Eyelet-Piercer). Ann Plast Surg 1993;31:159-61. 11. Gaul LE. Development of allergic nickel dermatitis from earrings. JAMA 1967;200:186-8. 12. Fischer T, Fregert S, Gruvberger B, et al. Nickel release from ear piercing kits and earrings. Contact Derm 1984;10:39-41. 13. Nakada, T, Iijima, M, Nakayama, H, et al. Role of ear piercing in metal allergic contact dermatitis. Contact Derm 1997;36:233-6. 14. Fischer T, Fregert S, Gruvberger B, et al. Contact sensitivity to nickel in white gold. Contact Derm 1984;10:23-4. 15. Fisher AA. Allergic dermal contact dermatitis due to gold earrings. Cutis 1987;39:473-5. 16. Simplot TC, Hoffman HT. Comparison between cartilage and soft tissue ear piercing complications. Am J Otolaryngol 1998;19:305-10. 17. Staley R, Fitzgibbon JJ, Anderson C. Auricular infections caused by high ear piercing in adolescents. Pediatrics 1997;99:610-1. 18. Cumberworth VL, Hogarth TB. Hazards of ear-piercing procedures which traverse the cartilage: a report of Pseudomonas perichondritis and review of other complications. Br J Clin Pract 1990;44:512-3. 19. Reiter D, Alford EL. Torn earlobe: a new approach to management with a review of 68 cases. Ann Otol Rhinol Laryngol 1994;103:879-84. 20. Borges A, Larrabee WF Jr. Controversies in wound repair. Am J Cosmetic Surg 1986;3:5-9.
OBJECTIVE: To describe and evaluate an ear piercing and earring retention method for individuals with metal hypersensitivity. SETTING: Private facial plastic surgery practice associated with a tertiary care medical center. METHODS: Thirty-one patients with a history of hypersensitivity to metallic jewelry (62 ears) underwent earlobe piercing with an intravenous catheter. RESULTS: None of the patients experienced an infection or hypersensitivity reaction. All patients were able to wear nickel-free earrings for short periods without using the shortened catheter. CONCLUSION: Using the distal shaft of an intravenous catheter as an earring post sheath is a safe and effective technique that allows hypersensitive individuals to wear earrings in pierced ears on a limited basis. (Otolaryngol Head Neck Surg 2001;125:93-5.)
T
he majority of the female population wears earrings, usually without incident. Ear piercing, a seemingly innocuous procedure, is actually fraught with complications.1-3 These include allergic dermatitis, infection, inflammation, bleeding, drainage, cysts, and tears. Metallic hypersensitivity causes unsightly and often uncomfortable inflammation in affected areas, making it difficult or impossible for patients to wear earrings. A variety of ear piercing techniques and instruments have been described in the literature. They include the use of an intravenous cannula, a trocar needle, a wire loop, a 30- and 16-gauge needle, magnetic earrings, a modified surgical forceps with needle and anvil, and a spring-loaded piercing gun.4-9 These are all innovative
methods, but the authors fail to relay patient outcome data. To date, only one study has evaluated the results of their technique, which uses an eyelet-type Teflon tube.10 We have devised a slightly different method of ear piercing and earring retention that permits hypersensitive individuals to wear earrings in pierced lobes. METHODS AND MATERIALS Thirty-one patients with a history of hypersensitivity to metallic jewelry (62 ears) underwent earlobe piercing. The anterior and posterior aspect of the earlobe was prepped with isopropyl alcohol. The earring location was marked with a sterile marking pen and then confirmed by the patient with a handheld mirror. One percent lidocaine with 1:100,000 epinephrine was injected with a 27-gauge needle. A 20-gauge intravenous infusion catheter was introduced through the earlobe from the anterior aspect in a slightly downward direction (Fig 1). Once entirely through the lobe, the needle was withdrawn (Fig 2). The catheter was cut to protrude 1 to 2 mm from either surface of the lobe (Fig 3). Patients were offered the option of bringing their own 14K gold (or higher) stud earrings or wearing stainless steel Coren (Hastings Corp, Chicago, IL) studs from office stock for one month. After soaking in isopropyl alcohol for 15 minutes, the chosen earrings were placed through the catheter shafts and their backs snapped into place (Figs 4 and 5). Patients were advised to gently clean the earlobe with soapy water on a daily basis and to abstain from twisting the catheter-shaft-over-earring-stud units. The daily use of antibiotic ointment was encouraged for the first week. The senior author replaced the catheter-stud units after 30 days with Coren stainless steel studs. Patients were given several shortened catheter shafts to use over their earring posts if and when they wanted to wear earrings known to incite a reaction. RESULTS
From the Department of Otolaryngology–Head and Neck Surgery, Jefferson Medical College, Thomas Jefferson University. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Washington, DC, September 24-27, 2000. Reprint requests: Anthony J. Cornetta, MD, Department of OTOHNS, 925 Chestnut Street, Sixth Floor, Philadelphia, PA 19107; email, [email protected]. Copyright © 2001 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/1/116787 doi:10.1067/mhn.2001.116787
All 62 piercings (31 patients) were placed in the soft tissue of the earlobe and not in the auricular cartilage. None of the patients experienced an infection or hypersensitivity reaction. All patients were able to wear nickel-free earrings without using the shortened catheter. Some individuals would occasionally re-insert the catheter to wear earrings known to incite a skin reaction. No lobe developed a cleft, and no patient developed a complication of the procedure or of subsequent 93
94
CORNETTA AND REITER
Otolaryngology– Head and Neck Surgery July 2001
Fig 1. A 20-gauge intravenous catheter is introduced into the earlobe from the anterior aspect in a downward direction.
Fig 3. After trimming the catheter, 1 to 2 mm protrudes from either side of the earlobe.
Fig 2. Once through the earlobe, the needle is withdrawn.
Fig 4. An anterior view of the earring stud within the catheter shaft.
earring use. None of the 18 patients still in contact at 2 years reported any complications. DISCUSSION
Metallic hypersensitivity is an irritative condition characterized by redness, itching, induration, and crusting. In the United States, nickel sensitivity is 10 times more common in women than in men, probably because women have greater exposure to jewelry that contains nickel.11,12 Earlobe piercing has been shown to sensitize individuals to certain metals.13 Nakada et al13 demonstrated that significantly more individuals with pierced ears had patch-tested allergies to nickel, gold, and mercury compared with those without piercings. Fischer et al12 demonstrated nickel release from stainless steel, gold, or silver-plated, and even “hypoallergenic” earrings. White gold and yellow gold have been shown to induce contact dermatitis in sensitive individuals.14,15 Three questionnaire studies have revealed that 73% to 93% of the adult female population has at least one ear pierced, and the majority of women without pierc-
ings desire ear piercing.1,2,16 Medical personnel, a relative or friend, or store clerk may perform ear piercing. It has been shown that the complication rate is not correlated with who carries out the piercing.1 Complication rates range from 34% to 52% and include contact dermatitis, inflammation, infection, bleeding, drainage, cysts, and tears.1-3 Allergic reaction and minor infection are the most common complications. Simplot and Hoffman16 demonstrated that piercings through auricular cartilage do not carry a statistically significant increase in the general complication rate when compared with soft tissue piercings. There is a trend, however, toward a higher infection rate when piercing through cartilage. Several cases of Pseudomonal and Staphylococcal perichondritis have been reported.17,18 All 31 patients in this study had previously worn earrings but discontinued use because of metal hypersensitivity. The earring tracts had closed because of the extensive length of time that most had avoided wearing earrings. Each patient agreed to undergo this piercing
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method with the hope of wearing earrings again. Patient selection is important because earlobes scarred by recurrent infections, as well as lobes of less than 4 mm thickness, are more likely to tear.19 None of the earlobes pierced in this study possessed either of these characteristics. The likelihood of earlobe clefting may actually decrease because of the zero incidence of infection with this method. Immediate local care of the pierced sites is also important, possibly affecting outcome. Cleaning the piercing sites with isopropyl alcohol and twisting the earring studs daily lacks any justification.20 This practice may actually thin the developing epithelial lining. CONCLUSION
Our method is safe and quick with no reported complications. Using the distal shaft of an intravenous catheter as an earring post sheath allows hypersensitive individuals to wear earrings in pierced ears on a limited basis. Ideally, this procedure best suits individuals who can wear either gold or stainless steel earrings without the catheter after 1 month. By leaving 1 to 2 mm of shaft covering the earring post beyond each surface of the pierced lobe, the earring ornament and post holder do not have sufficient contact with the lobe skin to provoke a reaction. This allows the patient to occasionally wear an earring containing a known allergenic metal. REFERENCES 1. Biggar RJ, Haughie GE. Medical problems of ear piercing. NY State J Med 1975;75:1460-2. 2. Cortese TA, Dickey RA. Complications of ear piercing. Am Fam Physician 1971;4:66-72. 3. Hendricks WM. Complications of ear piercing: treatment and prevention. Cutis 1991;48:386-94. 4. Zackowski DA. An IV cannula stent for ear piercing [letter]. Plast Reconstr Surg 1987;80:751. 5. Goff WF. Ear piercing: by whom? Eye Ear Nose Throat 1975;54:319. 6. Goldman L, Kitzmiller KW. Earlobe piercing with needles and wires. Arch Dermatol 1965;92:305-6. 7. Landeck A, Newman N, Breadon J, et al. A simple technique for ear piercing. J Am Acad Dermatol 1998;39:795-6. 8. Matarasso SL, Glogau RG. Surgical pearl: ear piercing facilitated by magnetic earrings. J Am Acad Dermatol 1994;31:485-6. 9. Duffy MM. A simple instrument for ear piercing. Plast Reconstr Surg 1967;40:92-3.
Fig 5. A posterior view of the earring stud within the catheter shaft.
10. Inoue T, Kurihara T, Harashina T. Ear-piercing technique by using an eyelet-type Teflon piercer (Eyelet-Piercer). Ann Plast Surg 1993;31:159-61. 11. Gaul LE. Development of allergic nickel dermatitis from earrings. JAMA 1967;200:186-8. 12. Fischer T, Fregert S, Gruvberger B, et al. Nickel release from ear piercing kits and earrings. Contact Derm 1984;10:39-41. 13. Nakada, T, Iijima, M, Nakayama, H, et al. Role of ear piercing in metal allergic contact dermatitis. Contact Derm 1997;36:233-6. 14. Fischer T, Fregert S, Gruvberger B, et al. Contact sensitivity to nickel in white gold. Contact Derm 1984;10:23-4. 15. Fisher AA. Allergic dermal contact dermatitis due to gold earrings. Cutis 1987;39:473-5. 16. Simplot TC, Hoffman HT. Comparison between cartilage and soft tissue ear piercing complications. Am J Otolaryngol 1998;19:305-10. 17. Staley R, Fitzgibbon JJ, Anderson C. Auricular infections caused by high ear piercing in adolescents. Pediatrics 1997;99:610-1. 18. Cumberworth VL, Hogarth TB. Hazards of ear-piercing procedures which traverse the cartilage: a report of Pseudomonas perichondritis and review of other complications. Br J Clin Pract 1990;44:512-3. 19. Reiter D, Alford EL. Torn earlobe: a new approach to management with a review of 68 cases. Ann Otol Rhinol Laryngol 1994;103:879-84. 20. Borges A, Larrabee WF Jr. Controversies in wound repair. Am J Cosmetic Surg 1986;3:5-9.