Guidance

Pseudomonas aeruginosa perichondritis associated with ear piercings: Information for ear and cosmetic piercing businesses

Published 25 September 2024

Overview

This guidance has been produced for ear and cosmetic piercing businesses. It seeks to raise awareness about potentially serious complications from upper ear or cartilage piercing, caused by bacteria such as Pseudomonas aeruginosa, and encourages ear and cosmetic piercing businesses to follow good infection prevention and control practices. The recommendations, which are based on expert opinion, are advisory and are intended to supplement the advice contained within the Tattooing and body piercing guidance toolkit that was published in 2013.

Intended audience

This guidance has been written specifically for ear and cosmetic piercing businesses to follow. Local authority environmental health teams, who have regulatory responsibility for ear and cosmetic piercing businesses in the UK, may find it useful to make reference to this guidance when they are giving advice to ear and cosmetic piercing businesses.

Background

Over the last 25 years there have been numerous published case reports of a medical condition, known as auricular perichondritis, that has occurred after upper ear piercing. Perichondritis is an infection of the skin and tissue covering the cartilage of the outer ear. The risk of developing an infection is higher in the ear cartilage than in the ear lobe. This infection is usually caused by Pseudomonas aeruginosa and seldom from Staphlyococcus aureus or other bacteria.

Acute symptoms of perichondritis are an intensely painful, red, swollen and often bleeding outer ear. Initial treatment with intravenous antibiotics is necessary. Infection can progress to abscess formation and necrosis (death) of the implicated cartilage can occur. The health implications are significant, including permanent deformity (known as ‘cauliflower ear’) that is difficult to reconstruct with cosmetic surgery.

Pseudomonas aeruginosa are known to be common water-borne bacteria and should be assumed to be present in tap water, albeit at low levels. Ear piercing practices can transfer these bacteria from water, or items made up with tap water such as green soap, disinfectant solutions or aftercare saline solutions, to the site of the piercing. Piercing breaks the skin and makes a hole in the cartilage, which allows for the introduction of bacteria.

There is no mention of the risk of post-piercing perichondritis within existing council-adopted byelaws or existing guidance in the UK. This means that ear and cosmetic piercing artists could, inadvertently, overlook this risk despite every intention to comply with health and safety requirements and follow industry standards.

Recommendations for ear piercing businesses and artists to follow

To help reduce the risk of Pseudomonas aeruginosa and other bacteria from causing an infection following ear-piercing, the following advice is offered.

General precautions

Action	Explanation
Practise good record keeping, using a client consent form, to enable contact or follow-up with clients after their piercing, should this be necessary.	In the event of an infection control problem arising it may be necessary to contact recent clients to check they are okay.
Provide verbal and written aftercare advice to clients, including advice to see a doctor if signs and symptoms of an infection occur.	Aftercare advice will highlight early warning signs of infection and will encourage clients to seek medical help if a problem arises.
Ensure adequate information, instruction, training and supervision of apprentices, trainees and new-starters.	Appropriate training of ear-piercing personnel is important. Lack of experience has been associated with causing an infection (poor aseptic technique for example).
Minimise workstation clutter.	A tidy workstation is easier to keep clean.
Use pre-mixed cleaning chemicals.	Any Pseudomonas aeruginosa bacteria present in tap water and used to make up a cleaning solution may inadvertently contaminate that cleaning solution or spray bottle.

Daily precautions

Action	Explanation
Use single-use sterile products where possible.	Single-use products do not need cleaning and are guaranteed to be sterile.
At the start of each day, flush the hot and cold water taps for 1 minute, then clean the taps and sink with a biocidal cleaner. If hot water is supplied by a water heater, flush daily for 1 minute on the hottest setting.	Flushing taps and water heaters will prevent water stagnation and bacterial growth. Cleaning after flushing will remove any bacteria present in the sink environment.
Use a separate cloth for cleaning around the plughole and cleaning the taps (or use a disposable cloth and clean the taps first before the rest of the sink and plughole).	The drain and plughole are more likely to harbour bacteria than the taps. To ensure that the water taken from the taps is as clean as possible, it is preferable to use a procedure that avoids transferring bacteria from the plug to the taps.
The hand wash sink must be solely used for hand washing.	Inappropriate use of the hand wash sink creates opportunities for cross-contamination to occur.

Periodic maintenance

Regular maintenance will help prevent the formation of biofilms that harbour bacteria.

Action	Explanation
Regularly use limescale remover in hard water areas.	The build-up of limescale around taps and sinks provides an environment for bacteria to harbour.
Check the mastic sealant around the sink and work surfaces and renew where necessary.	Water resistant surfaces are less likely to harbour bacteria and are easier to clean.
Check the sink for signs of poor repair, such as cracks. If the sink is cracked or damaged it should be replaced.	Cracks provide an environment for bacteria to harbour and make cleaning more difficult.
Check for sections of plumbing that are not in use or do not have a regular flow of water. If these are found, have them removed by a plumber.	Unused sections of pipework (known as ‘dead legs’) create pockets of stagnant water where bacteria will harbour.

Hand washing

Effective handwashing is essential to help prevent bacteria from transferring to the piercing site and causing an infection.

Action	Explanation
Follow a recognised step-by-step hand washing technique.	Handwashing is fundamental to good infection prevention and control. Harmful bacteria can remain if hands are not cleaned thoroughly.
Use alcohol gel after hand washing as an extra precaution.	Alcohol gel will kill any bacteria present in tap water or that have remained after hand washing.
Replace taps with lever (elbow operated) taps or use a paper towel to turn the tap off.	Washed hands can pick up bacteria from taps.
Avoid splashing water outside of the sink.	Items near the sink may be splashed with water that contains bacteria.
Portable hand wash units require daily cleaning and maintenance. They should be cleaned and disinfected, replenished with fresh water and the grey water receptacle emptied.	Bacteria will remain if cleaning and maintenance is insufficient.

References

Anderson, H. ‘Ear piercing and auricular chondritis caused by Pseudomonas aeruginosa’. Ugeskrift for Læger 2002: volume 164, issue 44, pages 5,145 to 5,147

Brown, C. and others. ‘Outbreak of Pseudomonas aeruginosa perichondritis associated with ear piercings and a contaminated water supply’. Epidemiology and Infection 2024:  Publication pending

Chowdhury, W. and others. ‘High ear piercing – a dangerous craze’. Mymensingh Medical Journal 2004: volume 13, issue 2, pages 201 to 202

Cleveland Clinic ‘Perichondritis: Symptoms, Causes & Treatment’. 2024

Cumberworth, V. and Hogarth, T. ‘Hazards of ear-piercing procedures which traverse cartilage: a report of Pseudomonas perichondritis and review of other complications’. British Journal of Clinical Practice 1990: volume 44, issue 11, pages 512 to 513

Durrani, M. and others. ‘Adolescent female with right ear redness’. Annals of Emergency Medicine 2017: volume 71, issue 5, pages 564 to 574

Evans, H. and others. ‘National outbreak of Pseudomonas aeruginosa associated with an aftercare solution following piercings, July to September 2016, England’. Euro Surveillance 2018: volume 23, issue 37

Fernandez, A. and others. ‘Post-piercing perichondritis’. Brazilian Journal of Otorhinolaryngology 2008: volume 74, issue 6, pages 933 to 937

Keene, W., Markum, A. and Samadpour, M. ‘Outbreak of Pseudomonas aeruginosa infections caused by commercial piercing of upper ear cartilage’. Journal of the American Medical Association 2004: volume 291, issue 8, pages 981 to 985

MacPherson, P. and others. ‘An outbreak of Pseudomonas aeruginosa infection linked to a “Black Friday” piercing event’. Plos Currents, Europe PMC: 2017

Mitchell, S. and others. ‘Pinna abscesses: can we manage them better? A case series and review of the literature’. European Archives of Oto-Rhino-Laryngology 2015: volume 272, pages 3163 to 3167

More, D., Seidel, J. and Bryan P. ‘Ear-piercing techniques as a cause of auricular chondritis’. Pediatric Emergency Care 1999: volume 15, issue 3, pages 189 to 192

Pena, F. and others. ‘Auricular perichondritis by piercing complicated with pseudomonas infection’. Brazilian Journal of Otorhinolaryngology 2006 :volume 72, issue 5, page 717

Rowshan, H. and others. ‘Pseudomonas aeruginosa infection of the auricular cartilage caused by “high ear piercing”: a case report and review of the literature’. Journal of Oral and Maxillofacial Surgery 2008: volume 66, issue 3, pages 543 to 546

Sandhu, A. and others. ‘Pseudomonas aeruginosa necrotizing chondritis complicating high helical ear piercing case report: clinical and public health perspectives’. Canadian Journal of Public Health 2007: volume 98, issue 1, pages 74 to 77

Sosin, M. and others. ‘Transcartilaginous ear piercing and infectious complications: A systematic review and critical analysis of outcomes’. The Laryngoscope 2015: volume 125, pages 1827 to 1834

Stewart, G., Thorp, A. and Brown, L, ‘Perichondritis – a complication of high ear piercing’. Pediatric Emergency Care 2006: volume 22, issue 12, pages 804 to 806

Tobar, D. and Kosoko, A. ‘Auricular perichondritis after a “high ear piercing”: A case report’. Journal of Education & Teaching in Emergency Medicine 2021: volume 6, issue 2, pages 30 to 33