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| Article 14 Appendix A, Suffolk County, New York |
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(Suffolk in bold type.) Suffolk Article 14 Body Piercing Appendix A Suggested Aftercare Guidelines for Body Art Procedures Piercing for body adornment has not attracted any attention from the
medical or scientific community. As such, there are no clinical trials or
scientific or medical studies published to help determine sound wound
healing techniques for a permanent hole though the skin. Eventually we hope
this will change. As a popular commercial practice it spread so fast public health could
only play catch-up when required to deal with the phenomenon. Not having any
medical literature to draw upon, sound healing practices were discarded in
favor of the testimony of local piercers. They thought they were giving good
advice based on what they were taught by other piercers and their customers
healed. But as been said previously, healing progressed in spite of what
piercers were advising. The most anyone saw was an occasional, easily-treated localized swelling with maybe some small pus discharge which wouldn't qualify to be called an infection which subsided rapidly with an increase of care and hygiene. As far as the physiology of healing we guess that primarily for healings like eyebrow and navel granulation tissue forms, toughens and lines the hole. When secretions stopped, redness around the hole vanished, no evidence of trauma remained and the bar moves freely without pain or discomfort we call it healed. Organizations that have sprung up have done little more than repeat the
errors they were taught and publish superficially understood guidance,
traditionally wrong. This void has left suppliers such as Unimax to develop
new products for the industry and do as much study and research as they
could to provide modern sound guidance to protect both client and piercer. Unimax introduce odd gauge size needles and tapers, the sleeved needle, the threaded needle, various tools, the first sterile tools and needles for the industry, promoted advanced skin products and provided leadership during the NY City legalization process, trained piercers and has been called upon as source of all types of advice pursuant to body art. Not being medically trained but having two decades of study relative to tattoo and more than a decade with piercing the following comments are based on published medical literature and life experience. Wound management techniques...have been ...ritualistic...procedures were not evidence base...p225 The message is being emphasized...which strongly links evidence-based practice with quality care. p225 Some areas of wound care have been well researched, and the guidance is clear...Other areas remain highly controversial...p225 Until further research is available the reader is advised to use the following technique... p236 An understanding of the wound healing process...is essential...p226
Body Piercing, General Aftercare a. First, wash your hands with soap and water and dry with clean paper towels. No cloth towels! Could be written. Do not touch your new piercing without first cleaning your hands. This
can be done by washing or using a cleansing towelette. If cloth towels are
fresh and clean they are appropriate. (CDC)
b. Soak area with sterile saline solution or a liquid anti-microbial cleanser 2-3 times daily. It may be easier to apply using saturated sterile gauze. c. Dry the piercing area with sterile gauze. Do not use cloth towels! Washing and soaking a wound up to 4 times (including daily showering) does not promote wound healing. Wound Cleansing "We need to consider when we should cleanse, how, and with what. The purpose of wound cleansing is to remove 'foreign bodies', excess exudate and bacteria from a wound. This is particularly important in infected wounds or those at risk for infection." p.239 ICC OpCit The purpose of washing is to remove foreign matter, bacteria and excess exudate (exudate that is beyond the borders of the wound because that exudate can cause harm to surrounding intact skin). This point can be eliminated because it is contrary to published wound healing techniques.
Salt One of the oldest remedies for perineal and other trauma is the addition of salt to the bathwater and this still appears to be popular. Salt is believed to soothe discomfort and speed the healing process but its precise mode of action is unclear. Claims that it has antibacterial or antiseptic properties remains unsubstantiated (Ayliffe et al 1975). There is no consesus as to the type or amount of salt to be used (Sleep 1990). A randomized controlled trial involving 1800 women compared three bathing policies. One group were asked to add salt, another group were asked to add savlon and the final group were asked to use no additives. Few if any differences were reported between the three groups in healing or infection rates (Sleep and Grant 1988). On the basis of these results, thre is no case for recommending the use of salt or savlon bath additives. p245 (Savlon Antiseptic Wound Wash: First Aid - Washing out minor wounds to help remove dirt & debris - Cuts & grazes - Insect bites & stings - Minor burns & scalds. Contains chlorhexidine gluconate. http://www.savlon.co.uk/frames_feat_products.html)
Definition: Isotonic:"when two solutions have equal solute concentrations (usually used with regards to describing solution on either side of a membrane). "http://www.biochem.northwestern.edu/holmgren/Glossary/Definitions/Def-I/isotonic.html ISOTONIC: Relating to isotonicity or isotonia. Having equal tension; denoting solutions possessing the same osmotic pressure; more specifically, limited to situations in which cells can neither swell nor shrink. http://www.condell.org/libertyville/neurosurgery/neurology-glossary.php?a=I Isotonic - having the same salt concentration as blood. http://www.shortbowel.com/glossary/i.asp Isotonic solution: A solution that has the same salt concentration as the normal cells of the body and the blood. As opposed to a hypertonic solution or a hypotonic solution. An isotonic beverage may be drunk to replace the fluid and minerals which the body uses during physical activity. http://www.medterms.com/script/main/art.asp?articlekey=4058 If a hyperosmolar solution was administered to a patient, this would tend to cause water to move out of the cell... water would move through the membrane from the side of lower solute concentration (or alternatively: higher H2O concentration) to the side of higher solute concentration... If the red cells swell and rupture, the test solution is said to be hypotonic compared to normal plasma. If the red cells shrink and become crenated, the solution is said to be hypertonic. If the red cells stay the same, the test solution is said to be isotonic with plasma. The red cell membrane is the reference membrane. Red cells placed in normal saline (ie 0.9% saline) will not swell so normal saline is said to be isotonic. http://www.qldanaesthesia.com/FluidBook/fl2_3.htm Accessed online 01-01-2006 Wes-if salt solution is greater than 0.9% cells release water. Solutions higher exert pressure on cells to absorb water.
d. You may shower daily, use soap and rinse thoroughly. A daily showering can be the cleaning. Life experience has hinted to us that air in the piercing hole, movement through the hole and an occasional washing may all contribute to an un-eventful successful healing. There is no information in the medical literature that we can locate. Dried exudate on the bar can be chipped off with a fingernail when noticed rather than wait for the shower. The bar should be played with moving it back and forth through the hole to prevent it from healing in place. If it is difficult to move a small amount of body lotion will free the bar. Any cleanser you are currently using for body wash that is tolerated by your body can be used.
e. During healing one might experience some bleeding, localized swelling, tenderness, bruising, discoloration, itching, secretion of a whitish-yellow fluid (not pus) that will form some crust around the jewelry as the piercing heals. f. A piercing heals from the outside inward and thus may appear healed before healing is complete. Be Patient! During healing bleeding is not expected unless subjected to trauma. The other reactions do occur but should not increase in intensity. Point f. comes from Gauntlet teaching that epidermal cells grew from the outside and formed a tunnel. We only can confirm this for the ear and some large gauge navel piercings.
g. Maintain clean, comfortable bedding and clothing. This needs more emphasis because it is our belief that all infections come from contamination by the client.
h. Avoid the following: -Undue trauma or playing with the piercing. Be careful not to pull, twist, squash or injure your piercing. It is good to play lightly with your piercing moving it through the hole back and forth. If you do not play with the jewelry, it can become stuck in position. -The use of alcohol, hydrogen peroxide, Betadine, Hibiclens or ointments. Do not use or apply anti-bacterial except alcohol to clean the bar. Alcohol on the skin, or alcohol rubs followed by moisturizer is OK. Wiping the bar with alcohol is good idea. -Over-cleaning Of course 3-4 times a day washing is considered over-cleaning. -Oral contact, rough play, contact with other people's body fluids. Needs emphasis. -Stress, recreational drug use, excessive caffeine, nicotine and alcohol. This seems like good advice but should be removed not being accurate and misleading clients into thinking these were all approved life-style choices but to be avoided during piercing healing, as long as moderate. -Submerging the piercing in bodies of water such as lakes, pools, hot tubs, Jacuzzis, marine water, etc. This would be better expressed as: Avoid lakes, pools, hot tubs, Jacuzzis, marine water which may contain high levels of microbes. -All beauty and personal care products such as cosmetics, lotions, sprays, etc. on or around the piercing. It is probably not true that normal use of cosmetics poses a danger to piercings. The eyebrow and ear seem to experience minor easily treated flare-ups that are not considered infections. It is not known if cosmetics play any role though common sense would be that they should not be put directly on the piercing. -Do not pick at the crusted matter at the piercing site, this is dried lymph fluid secreted by your body to cleanse the piercing. -The crusting should come off during your routine soaking & cleansing period only. There is no evidence to suggest these two points. Just because the crust can come off in the shower does not mean that is the only way. It is good to pick at any dried crust on the bar to remove it not waiting for showering. If one suspects, in any way, that the piercing might be infected, immediately seek medical attention.
Risk Factors, Epidemiology of Nosocomial Infections. "For the first week or two of central catheterization the skin is the principal source of microorganisms contaminating and infecting the catheter." Infectious Disease p.113
There is legitimate debate about the merits of identifying and reporting superficial post operative wound infections." P.110
Patients who acquire infection are almost always inherently sicker and receive more intensive and invasive medical care than patients who do not." P.111
Body piercings; Additional Specific Aftercare for Particular Areas This section could be left out of the Article and considered as part of specific ways to help healing provided by the body artist.
Healing: There is little to go by in the medical literature to clearly understand how piercings heal. In the early 90's Gauntlet taught that the epidermis grew into the hole and made a tunnel. We have discarded this notion except for the ear lobe and guess that granulation tissue forms, dries and lines the hole (eyebrow, navel). When secretions stop and the redness around the hole vanishes, we call it healed. Salt water has always been around even though studies show salt water does not promote healing in wounds. This may indicate that excess salt (clients will never make a proper saline solution) causes water to leave the surrounding cells by osmosis drying the passageway and effectively sealing it. We can look at the ear and say the epidermis grows to the other side and we can see this happening. A nipple does not have an epidermis. The eyebrow and navel go through some fatty tissue. The tongue heals around the hole the way an earlobe heals. The labret may heal from the inside out. The best that can be done is to provide an environment for cleanliness and movement in the hole. a. The Navel 1. A hard, vented eyepatch (sold at pharmacies) can be applied under tight clothing or secured using a length of ace bandage around the body (to avoid irritation). This can protect the navel from restrictive clothing, excess irritation, friction, and impact during physical activities such as contact sports. 2. Do not routinely use this to cover the piercing and do not use it for extended periods of time. Its use should not inhibit adhering to your normal soaking & cleaning routine. This sounds good, but upon testing the eyepatch does not work. 2. Based on personal testing a wide 4-inch ace bandage is necessary. When wrapped around the body the bandage is very irritating. After a half hour of sitting, moving and standing the eyepatch moves out of position in spite of even the adhesive type of Ace bandage. The eyepatch itself would have to be strongly taped to the skin. This suggestion is not viable when put to the test and should be removed. It is disappointing that a mere idea would be put into the Article without testing. The Article claims that (a) above is Additional Specific Aftercare for Particular Areas but on examination this Ace bandage is not specific aftercare for the navel at all. Specific Aftercare would include things like: Do not wear tight clothing over the piercing, especially belts; sleep on your side or back; be careful not to get it caught when washing or dressing.
b. Ear, Ear Cartilage and Facial 2. Maintain cleanliness of telephones, headphones/earphones, eyeglasses, helmets, hats and anything else that contacts the pierced areas. 3. Use caution when styling your hair and advise your stylist of a new or healing piercing.
c. Nipple Use of a tight or snug, clean cotton shirt or sports bra may provide additional protection and make the piercing more comfortable, especially for sleeping or reclining. This is just plain wrong. Tight fitting clothes are to be avoided. It would be better to use a large loose band aid during the first few days because the nipple is very sensitive to friction.
d. Genital 1. Comfort and hygiene are vital. Initially, abstinence is strongly recommended. 2. Be patient & pursue sexual activity only if your feel ready and comfortable. 3. During healing, all sexual activities must be gentle. 4. Prior to sexual activity and to reduce trauma and increase comfort, soak piercing in warm saline solution or plain water to remove any crusty matter. 5. Use clean, disposable barriers such as condoms, dental dams, and Tegaderm to avoid contact with sex toys and partner's body fluids, even in long-term relationships. 6. Use a new container of water-based lubricant; do not use saliva as a lubricant. 7. After sex, perform an additional soak or cleansing with clean saline solution or water. 8. Some piercings can bleed freely for the first few days. 9. After cleansing a piercing near to or including the urethra area with a mild soap, be sure to urinate. This long list of detailed sex help is without justification and would be
embarrassing. As with all piercings clients must avoid contamination with
body fluids, avoid trauma and keep their piercing clean. e. Oral 1. Use an antibacterial, alcohol-free mouth rinse or sterile saline solution for 30 to 60 seconds after eating and at bedtime while your piercing heals. 1. Rinse after eating to prevent food from being caught in your piercing. Plain water is fine. 2. Use a new soft-bristled toothbrush after the piercing to avoid introducing bacteria into your mouth. 2. Be careful not to traumatize your piercing with your toothbrush. It has nothing to do with bacteria and soft bristles as opposed to medium can hurt the piercing just as much. It's enough to warn to be careful when brushing or flossing. 3. For exterior surfaces of cheek and lip piercings, follow the entire General Aftercare Instructions in Section 1 of this Appendix. 3. Cheek reference should be deleted and needs discussion. 4. Eat slowly taking small bites of food placed directly onto molars. Avoid eating spicy, salty, acidic, or hot temperature foods or beverages for several days. 5. For tongue piercings, try to keep the tongue level in the mouth while chewing and swallowing. For cheek and lip piercings, avoid opening the mouth too wide as this can result in the backing of the jewelry catching on the teeth. All these are believed to be helpful but should not be part of the Article proper.
Tattoo Aftercare This section is improper, will delay healing and promote infection. a. First, wash your hands thoroughly with mild soap and water and dry your hands with clean paper towels. No cloth towels. b. The dressing may be removed after approximately 4 hours. D. Using a sterile gauze or dressing, gently pat the area dry. Do
not rub. Do not use a cloth towel. g. If there is any reason to suspect an infection of the tattoo or its surrounding area, immediately seek medical attention. h. Avoid soaking the tattoo in pools, spas, Jacuzzis, hot tubs,
beach water, baths etc.
Wound Cleansing "We need to consider when we should cleanse, how, and with what. The purpose of wound cleansing is to remove 'foregin bodies', excess exudate and bacteria from a wound. This is particulary important in infected wounds or those at risk for infection." p.239
Removing Exudate Exudate is required on the wound surface to maintain phagocyte levels, as well as other wound-healing hormones and chemical stimuli. Wound irrigation will remove these and is therfore best avoided." p.239-240
The rationale for different cleansing solutions. "If wound irrigation is deemed necessary...a decison..sterile or clean....Many nurses are now using non-sterile...Tap water is not isotonic...water may be drawn into the tissues ...through the cell walls, causing the cells to rupture. Minimal contact time is therefore advocated. Isotonic (normal) 0.9% saline is currently the sterile solution of choice...." Antiseptics for wound cleansing. "In general they should only be used for a specific purpose, as an adjunct to antibiotic therapy..."p240
Scabbing A Scab or crust is a formation of necrotic cells, necrotic tissue, fibrin, and blood products. Some components of the dermis are also present in the scab, including collagen and elastin fibers. The scab is a defensive reaction to protect the underlying tissue from the dry, open environment. The skin sacrifices the exposed cells and tissue to form a protective barrier. The scab is inhibitory to epidermal growth. A vapor-permeable membrane that provides a moist environment enhances superficial wound healing. The epidermal cells are slowed by a scab because the cells must migrate underneath the scab and travel farther. The epidermal cells must mechanically loosen the scab with proteases, including collagenase and elastase, further slowing growth.... Treatment of acute wounds relies on enhancing and focusing the processes of the skin. Promotion of epidermal migration and wound coverage is essential. As mentioned earlier, minimizing the scab can speed and improve epidermal healing. A humid environment enhances healing. Therefore dressing usually are made to maintain moisture in the wound. Application of ointments, medications, or dressings is designed to optimize the local environment. p. 762 L.S.Moy, MD Management
Occlusive Dressings Occlusive dressings can be very useful for rapid wound healing. Epithelialization takes 2 to 3 days with air exposure, but occlusion shortens the healing time to 18 to 24 hours. Occlusive dressings are advantageous for wound healing because the occlusion speeds healing, prevents environmental trauma, and keeps bacteria out of the wound. Also, the discomfort from the wound is reduced and the dressing does not require daily changes. p764 Management of Acute Wounds,
...wounds covered with an occlusive dressing healed 40% faster than those left air-exposed...In addition to speeding the rate of wound healing, occlusive dressing also decrease pain and improve the cosmetic outcome of wounds...p635 K&E Op Cit Humidity The correct balance of humidity can be achieved under an occlusive dressing. The type of dressing will depend on whether there is a need to absorb exudate to prevent this damaging the surrounding skin causing excoriation and maceration. It has been suggested that the use of an occlusive dressing encourages the multiplication of bacteria (Bennett 1982). It is now known that the exudate trapped under the dressing contains a large number of white cells, hormones, and chemical stimulants which digest bacteria and promote wound healing. An occlusive dressing will prevent the entry of new bacteria to the wound and the transfer of bacteria to other people through contact or airborne distribution from the wound. Gilchrist and Reed (1989) found that occlusive dressings did not increase the risk of infection or encourage the growth of anaerobic bacteria. It has been found that wounds dressed with occlusive dressings are less likely to become clinically infected (Hutchinson and Lawrence 1991). p241
Film Dressings Although these dressings on their own are only suitable for minimally-exudating wounds, they are useful as a waterproof secondary dressing to prevent strikethrough with infected wounds. p242 ICC, If dressings are used which allow strikethrough (the appearance of wound exudate which has soaked through to the outside of the dressing), then contact with the dressing will result in contamination, and bacteria may then be easily passed on to other residents via hands. If occlusive dressings are used and changed before saturation occurs, then the risks of cross infection will be minimized. p239
Wounds in a moist environment demonstrate a faster and more direct course of epithelialization. Occlusive and semiocclusive dressings applied in the first 48 hours after injury may maintain tissue humidity and optimize epithelialization. http://www.emedicine.com/ent/topic13.htm http://www.hon.ch/HONcode/Conduct.html
TOPICAL AGENTS The use of antiseptices to kill the microflora in the wound environment can alter wound healing. Most harsh chemicals that make up antiseptic solutions harm not only microflora but also delicate, newly forming skin. Hibiclens, a chlorohexidine-based antiseptic, is a very effective topical antiseptic for intact skin, but it has been shown to be toxic on the wound environment...warned health care professionals...its use has been associated with corneal opacification....p745 Another antiseptic that is very effective on intact skin is providone-iodine solution..(but)..is toxic to fibroblasts...have suggested that it should not be used in wounds....at best...it has been shown to be ineffective in controlling microorganisms in the wound...triple antibiotic ointment...found to be the most beneficial...Bacitracin Zinc was found to be the component of the triple antibiotic ointment that was associated with faster epithelialization. ... Other topical treatments, such as anitseptics, can injure tissue and make infection more probable... The use of a particular antimicrobial agent in chronic wounds is not advised without first establishing the presence of specific organisms against which it is known to have a spectrum of activity.p.742 Wound Healing Microbiology, P. M. Mertz, BA and L.G.Ovington, PhD, DC Op Cit
One of the majopr misconceptions in the treatment of acute wounds is the use of topical agents. Although antimicorbial solutions are effective in cleaning intact skin, convincing data on their effectiveness in speeding wound healing does not exist. Many physicians still use these agents, either out of habit or because most of their patients heal in spite of them. on fact, many antimicrobial agents have been found to inhibit either cell proliferation or migration in vitro. Our practice with regard to all topical agents in acute wound healing is "Prime, no nociere" (first, do no harm); that is, in the majority of cases we do not use them. p635, R.S.Kirsen MD and W.H.Eaglstein MD The Wound Healing Process, DC Op Cit
Management of Wounds (Cooper and Lawrence 1996), Harding (1996) advise against their (antiseptics) 'wide-spread and indiscriminate use'... ...it may be appropriate for...immunocomprimised patients...bacteria can never be completely eradicated from the skin and antiseptics have no healing properties...so the continual and unselective use of antiseptics is of questionable value." ICC, Wound Care t p237
Tattoos Little is known regarding the natural history of an intradermally placed tattoo. http://www.emedicine.com/derm/topic563.htm
Tattoo Healing by Westley Wood During a tattoo the skin secretes fluid forming droplets on the surface. If the blood particles in the fluid dry on the surface they stick on the surface looking like little black specs. If allowed to remain they adhere strongly and other damaged cells and particles accumulate, they dry and begin scab formation. Scabbing prolongs the healing process because epithelial cells must grow beneath this heavy burden scab to seal the skin. Eventually though the skin will heal in spite of the obstacles created.
Presuming minimal physical damage to the skin, the speed of healing is related to the amount of moisture in the area. The three top rated healing ointments are Bacitracin Zinc, A & D Ointment and Petroleum. It is the petroleum in these products that produces the best healing speed because it makes the skin occlusive. Occlusive means neither water nor air can penetrate to the skin surface. The skin responds to an occlusive condition by providing moisture to the area internally providing the ultimate healing condition.
When a tattoo is just finished there is generally no oozing (exudate) and the surface is relatively dry (an indication that the procedure did not excessively damage the skin). When a petroleum product is applied (an occlusive condition is created) droplets of fluid will begin to appear because the body is producing exudate. Exudate is necessary to create an environment which stimulates rapid wound healing. By allowing the area to dry (which we should not), the beneficial cells are removed, cells dry, necrose and even serve as a bacteria medium. A wound maintained in a moist environment with exudate has a lower infection rate than a wound which is dry.
Because this mechanism of the body was not understood it was thought petroleum caused ink to leave the skin. Today we know this is not true. Three or four days is required for new epidermal cells to grow across the surface. Damaged cells will float on the top of the new cells until removed. Light amounts of petroleum or moisturizing lotions should be continued for another week but Bacitracin, if used, should not be used for more than 3 or 4 days. The constant application of antibacterials is not necessary to avoid infection. Antibacterial products actually interfere with the wound healing process.
An ideal procedure, immediately after the tattoo is finished, would include applying a petroleum based ointment and watching the area for oozing and droplet formation instead of bandaging and sending the client away. If the droplets that ooze to the surface are pink they should be dabbed off carefully, or the area lightly rubbed periodically to prevent platelet and dead cell buildup. Removing those little black specs as soon as they appear will speed subsequent healing. This should be repeated until no pink oozing is seen and the area is clear colored. Now the client has a good chance for fast healing. After this, the ointment should be applied heavily enough to look shiney. Too thin and the surface will dry and prolong healing. Ointment applying and plastic wrapping for the shower or sleeping for a few days will help protect the tattoo under adverse conditions.
Procedures that recommend immediate bandaging and being left on for several hours and then the area washed, or washed every day are not conducive to speedy healing. This is not best practice.
Bandaging is necessary if the area may be irritated or exposed to foreign matter.
Washing interferes and prolongs healing but should be done if dead cells have accumulated on the surface. Allowing the tattoo to accumulate dead cells and other necrotic matter for 8 or 24 hours is counter-productive to healing speed and will then require washing to remove as much of the dead material as possible. Good tattoo technique will produce preliminary healing in 3-4 days and should not be attributed to any new miracle healing preparation we have discovered or been sold, but to the healing abilities of the skin, the good tattoo technique of minimal damage and good aftercare with a petroleum product.
There are plenty of promoters of "miracle" new healing preparations who want to separate you from your money.
Reactions to antibacterial ointments look like small pimples around the area of application in which case the ointment should be discontinued and a moisturizer applied until healed.
There are many different procedures followed for tattoo healing that have been used for years by different artists. Any one could be argued for based on individual testimony and experience: "their customers healed." The reason for the healing is often attributed to the wrong cause because there is no understanding of the healing process of the skin and what produces more ideal conditions for repair. The explanation above does not rule out any other favored procedure. It should be kept in mind that it is the skin itself that does the work of repair, not us, and will repair itself, sooner or later, not because we are doing or using x, y or z, but in spite of the challenges we present to the skin. Thank Goodness for that.
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Wes Wood Comments, corrections, errors? Please reply to LUCKISAGOODTHING@yahoo.com These are personal views
and opinions of Wes Wood and do not necessarily represent the views and
opinions of Unimax Supply Co Inc. |