Teens and Body Art- Into the Mainstream


From Medscape Nurses

Laurie E. Scudder, MS, PNP

Posted: 02/05/2007

Adolescent Development: Things Change

The one constant about adolescents is that nothing is constant — and that has been developmentally consistent throughout the generations. One of the most visible signs of changing cultural norms for today’s adolescents has been the movement of body art into the mainstream. Once considered a mark of a rebel or outcast, tattoos and numerous body piercings have become very common, almost a rite of passage for teenagers.

A unique and interesting session presented by Margaret Graham, PhD, CRNP, Professor, Wright State University, Dayton, Ohio, and Alice Teall, MS, CRNP, Clinical Assistant Professor at Wright State, focused on the assessment of normal and abnormal appearances in the teen years.[1]

The session began with a review of adolescent developmental theory, promulgated by the noted psychologist David Elkind. Elkind emphasized that the growing ability to engage in abstract thinking, first prominent in early teens during a period of tumultuous physical growth and change, causes teens to wonder what others are thinking. The combination of these 2 forces creates the notion for them that everyone is thinking about the same thing, namely themselves.

This belief that “everyone is looking at me and thinking about me because that’s what I’m thinking about” leads to a concept termed the “imaginary audience.” This leads to teens filtering their behavior through the lens of others’ perceived views and observation, and leads to the self-centeredness so typical of late middle school and early high school. The logical conclusion of this belief that everyone is watching you is that the reason for the audience’s attention is that the teen is someone indeed special. This belief in their own uniquenesss and specialness, termed a “personal fable” by Elkind, leads to the concept that the laws of nature do not apply to oneself, which is the underpinning of adolescent risk-taking behavior. Teens believe that nothing bad will happen to them, that they will not suffer the consequences of this behavior, because it is not part of their image and fable.

Body Art — An Increasingly Common Practice

A belief in one’s own uniqueness can be expressed through body art. Teens may engage in body art for a number of reasons, including a desire for social bonding. Adolescents, in a period of identity formation, may engage in art that allows them to look like their peer group or commemorate a friend or loved one with their art. The speakers reported that the National Longitudinal Study of Adolescent Health, conducted in the mid 1990s, found a rate of tattoos of 4.5% in teens, with an average age of 16.8 years at the time of tattooing. Ten years later, the rate had risen to 14%, indicating that tattooing has moved into mainstream culture. (Complete study results are available for purchase at http://www.socio.com/srch/summary/afda2/fam48-50.htm.)

While adults may view piercing and tattoos as deviant behavior, to adolescents it is truly beautification. Body art, particularly tattoos in commemoration of a loved one, are usually associated with a story and may provide an entrée for a provider to relate to a teen in their practice.[2]

However, body piercing may also serve as a marker of an at-risk teen, with some studies reporting a significant relationship between piercing and substance abuse.[3] Other studies of high school youth have found that tattooing was significantly and independently associated with other high-risk behaviors, including sexual intercourse, binge drinking, smoking, marijuana use, gang membership, truancy, and school failure. However, surveys of college students have not found an increased frequency of high-risk behavior in this population. Students with and without body art shared similar family, personal, and demographic characteristics.[4]

Caring for Tattoos and Piercings

Educating teens about important considerations in choosing a tattooist or facility for piercing, as well as the after care and healing associated with these practices, is an important role for nurse practitioners (NPs).

Safe Piercing

While many teens may choose to perform their own piercings, or have friends perform this task for them, there is a greater risk for infection in these instances. Encourage teens to wash hands before and after piercing, keep the area clean with antibacterial or antimicrobial soap, and refrain from touching the pierced body part until healed. Advise teens to avoid alcohol and hydrogen peroxide, which may cause tissue destruction and delayed healing. Healing times vary significantly by site (Table).

Teens with tongue piercings should be advised to use antiseptic, nonalcohol mouthwash after meals. They should avoid smoking and refrain from deep kissing. Dental dams or condoms during oral sex are recommended.

Infections are typically associated with organisms common to skin, including Staphylococcus aureus, group B Streptococcus, and Pseudomonas. Local infection may be treated with warm compresses and topical antibacterial ointments. Ideally, jewelry should not be removed as it will serve as a portal for drainage. The exception is infections suspected to be secondary to a nickel allergy.

While generally safe, piercing can cause a variety of adverse reactions, depending on body part. Tongue piercing may cause damage to teeth and gums, including dental fractures and changes in mastication and speech. Permanent nerve damage can occur with piercing of any body part, as can scarring, rejection, and migration of the piercing, along with possible keloid formation. The possibility for transmission of hepatitis and HIV exists.

Table. Average Healing Times for Body Piercings by Site

Ear lobes 6 weeks
Ear cartilage 1 year
Lips 2-3 weeks
Tongue 1 month
Nose 1 year
Eyebrow 6-12 weeks
Navel 6-12 months
Nipple 2-4 months
Genitals 3-6 weeks

A relatively new practice is “gauging,” which is the insertion of progressively larger circular discs into the pinna, resulting in a larger and larger opening that can be filled with objects ranging from corks to coins.


Commercial tattoo artists may be found in sites such as rock concerts, flea markets, or commercial studios. Typically, tattoos are applied using an electrically powered, vertically vibrating handheld device that is held several centimeters away from the skin and functions like a sewing machine with a needle bar that moves in and out of the skin from 50 to 3000 times a minute. Several needles may be attached to the end of the brand and are responsible for inserting the pigment into the skin. Pigments, which are not regulated by the US Food and Drug Administration, include metallic salts, India ink, and synthetic organic dyes.

Self-administered tattoos may be performed using sewing needles, forks, paper clips, or pens, and dyes may include charcoal, soot, mascara, or ink. Adolescents may obtain amateur tattoos either because they cannot find a studio that will tattoo minors or because they can’t afford professional tattoo rates.

Adolescents who have 1 tattoo are very likely to acquire a second; therefore, the NP has an opportunity to educate the teen about points to consider when selecting a tattoo artist. Teens should determine that equipment is sterilized using an autoclave and that paints are discarded after use. Tattoo technicians should wear gloves and should cover the tattoo until fluid leaking abates.

While tattooing is assumed to be associated with health risks, the true incidence is unknown. Dr. Graham emphasized that there is little state regulation of the industry and in only 9 states are licenses required for artists. No states require formal training.

As a result of extensive skin puncturing, tattooing causes bleeding and prolonged leaking of serosanguinous fluid. Tattoos should be covered until the bleeding and oozing ends; tattoos will scab before healing. Reaction to tattoos includes hypersensitivity and local sloughing; infections and dermatitis may also occur.

Tattoos should be cleaned with antibacterial soap twice daily until healed. While antibiotic ointments seem reasonable, they may cause dyes to fade. Therefore, a petroleum-based ointment may be used to keep the area moist and prevent scabbing. Scratching, swimming, hot tubs, and saunas should be avoided until healed, which may take up to 4 weeks. Since sunlight fades the ink, adolescents should be encouraged to wear sun block.

A new phenomenon is called “branding,” meaning the use of a heated, metal brand to sear the skin and cause a patterned scar. Branding causes third degree burns that may spread during the branding process as a result of a widening burn and tissue damage. Branding burns may take up to a year to heal.

Abnormal Adolescent Appearance and Behaviors

Alice Teall MS, NP, continued this important session with a focus on identifying those teens whose behavior requires intervention. Increasingly, NPs in primary care, adolescent, and school-based practices will interact with teens who are in crisis. The rate of anxiety and depression in adolescents may be as high as 1 in 8, yet only one third receive help.[5]

Because of the prevalence of major depression, mood, and anxiety disorders in adolescents, teens whose appearance and/or behavior is outside of the normal self-expression expected should be carefully screened. Adolescents in crisis may demonstrate behaviors that indicate anxiety, depression, disengagement, and/or substance abuse. Signs that indicate this inner turmoil include self-injury and increased risk-taking behavior. Objective methods of assessment that can be used in a variety of settings are critical.

It is critical that NPs assess teens for characteristics associated with major depression. A helpful mnemonic is SIGECAPS: Sleep problems (hypersomnia or insomnia), Interest (lack of interest in appearance or previously enjoyed activities), Guilt (inappropriate amounts), Energy loss, Concentration problems, Appetite (increased or decreased), Psychomotor changes, and Suicidality (current or previous ideation or plan).

While SIGECAPS is helpful in distinguishing unipolar depression, teens should also be carefully screened for mania, especially prior to initiation of pharmacotherapy. Experts estimate that 25% of teens with depression have or will develop bipolar disorder. The mnemonic DIGFAST can assist with this assessment: Distractability, Insomnia, Grandiosity, Flight of ideas, Activity, Speech, and Thoughtlessness. NPs should assess teens for behaviors associated with mania or hypomania, including destructive rages, jumping out of cars or other risk taking, substance abuse, high-risk sexual activities, challenging authority, and extreme fluctuations in mood.

Increasingly, teens experiencing overwhelming sadness or anxiety are cutting or hurting themselves to relieve their emotional pain. This practice of self-harm or self-injury, while maladaptive, allows for an endorphin release that can be quite addicting. Teens who wear long sleeves or clothing inappropriate for weather should be assessed for cuts, burns, carvings, or bruises that are self-inflicted. Common areas include arms, wrists, and legs.

The prevalence of self-injury is unknown, though it is believed to be a growing problem. A variety of social, cultural, and peer group influences likely affect the incidence of self-injurious behaviors, including ever-increasing Internet use. Self injury may also reflect disordered impulse control or an attempt to communicate distress. The 2003 Youth Risk Behavior Survey found that 18% of high school students reported having deliberately injured themselves in the previous year.[6] While self-injury is believed to be a low-lethality behavior, teens who hurt themselves are at increased risk for suicide related to their underlying anxiety or depression. The increasing incidence makes deliberate self-harm a problem that all NPs dealing with adolescents are likely to encounter.

Teall emphasized the importance of an open and nonjudgmental approach, particularly warning against a first response to a teen’s appearance that conveys either shock or pity. Management is multidisciplinary and includes behavioral management, cognitive treatment, and family strategies. Often, however, an NP will be the prescribing healthcare professional and thus involved in the provision of antidepressants. A number of medications have been used successfully with teens, though fluoxetine (Prozac, Eli Lilly), a selective serotonin reuptake inhibitor, has been the most studied. Drugs in other classes, including dopamine and norepinephrine reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, and serotonin antagonist and reuptake inhibitors, are also approved for use in teens with unipolar depression.

Since depression often occurs in conjunction with other disorders, including anxiety disorders, attention deficit disorders, substance abuse, and psychosis, young people may be on a variety of medications. Thus, management can be complicated and may require consultation with a psychiatrist.



  1. Graham MC, Teall A. From self-expression to self-harm: the “normal and abnormal” outward appearance of teens. Program and abstracts of the American College of Nurse Practitioners National Clinical Conferences; October 11-15, 2006; Orlando, Florida.
  2. McGuinness TM. Teens & body art. J Psychosoc Nurs Ment Health Serv. 2006;44:13-16.
  3. Roberts TA, Auinger P, Ryan SA. Body piercing and high-risk behavior in adolescents. J Adolesc Health. 2004;34:224-229.
  4. Mayers LB, Judelson DA, Moriarty BW, Rundell KW. Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc. 2002;77:29-34.
  5. National Mental Health Association. Children’s mental health statistics. Available at: http://www1.nmha.org/children/prevent/stats.cfm. Accessed January 9, 2007.
  6. Massachusetts Department of Education. 2003 Youth Risk Behavior Survey Results. Available at: http://www.doe.mass.edu/cnp/hprograms/yrbs/03/results.pdf. Accessed January 9, 2007.

Authors and Disclosures

As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines “relevant financial relationships” as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Laurie E Scudder, MS, PNP

Medscape Accreditation Coordinator, Continuing Education Department; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC

Disclosure: Laurie Scudder, MS, NP, has disclosed that she has received grants for educational activities from Pfizer and owns stock in Procter & Gamble and Johnson & Johnson.

The materials presented here were prepared by independent authors under the editorial supervision of Medscape and do not represent a publication of the American College of Nurse Practitioners. These materials and the related activity are not sanctioned by the American College of Nurse Practitioners or the commercial supporter of the conference, and do not constitute an official part of that conference.

Medscape Nurses © 2007 Medscape, LLC

Contents of ACNP 2006: Caring for Today’s Adolescent

  1. Teens and Body Art — Into the Mainstream
  2. Eating Disorders in Young Men and Women


Please enter your comment!
Please enter your name here