Knowledge and Attitude Towards Cutaneous Complications of Tattoos and Piercings Among the General Population in Saudi Arabia

Introduction Tattooing and piercing, which were uncommon in affluent countries, have recently spread throughout societies. Over the past two decades, young people have shown considerable excitement for the practice. This reported growth creates more difficulties because of the numerous operations performed without awareness of health and hygiene requirements. This study aims to assess the knowledge and attitudes of the general population toward the cutaneous complications of tattoos and piercings in Saudi Arabia. Methods This was a web-based descriptive cross-sectional study. An online questionnaire was developed by the study researchers, which included participants’ demographic data, their knowledge of tattoos and piercings with associated health effects and possible infections, their attitude towards tattoos and piercings, and their practice and experienced complications regarding tattooing and body piercing. The final validated questionnaire was made publicly available via social media until no more new responses were obtained. Results Eight hundred and forty-eight individuals completed the study questionnaire. The ages of the participants varied from 18 to more than 55 years old, with a mean age of 25.2 ± 13.9 years, and (589 [69.5%]) were female. The most reported health effects and infections were bacterial infections in place of body modification (479 [56.5%]), purpura (380 [44.9%]), cutaneous abscesses (380 [44%]), melanoma (338 [39.9%]), hepatitis B virus (321 [37.9%]), HIV (311 [36.7%]), sepsis (306 [36.2%]), allergic contact dermatitis (296 [35%]), and hepatitis C virus (279 [33.1%]). In total, 336 (39.6%) had an overall good knowledge of tattooing and body piercing hazards, with higher knowledge among females with high education (p< 0.05). Conclusion This study revealed that one in three individuals knew about the health risks and infections associated with tattooing and body piercing. Higher awareness was found among females with high education levels. Of all the associated complications, procedure-related infections were the most common among participants.


Introduction
Body modification, also known as tattooing or skin piercing, is now a dominant practice, especially in modern cultures.The growing incidence of people opting for ink body painting has attracted the attention of academics worldwide [1,2].However, this growing demand has increased the number of unprofessional body art practitioners performing procedures that require more adherence to safe and healthy hygienic standards [3].Consequently, the frequency of recorded adverse health hazards after tattooing has increased [4].The prevalence of cutaneous complications of tattoos ranges from 2%-43% [5,1,6], even though the cutaneous complications are higher than the systemic complications.A survey of 3411 participants showed that 2302 (67.5%) developed skin problems, while only 225 (6.6%) reported extracutaneous problems [1].
Despite the vast research assessing the knowledge of the global complications of tattooing and piercing, little is known about the topic in Saudi Arabia.Therefore, this study evaluated the knowledge and attitudes about the cutaneous complications of tattooing and piercing among Saudi people.

Materials And Methods
A descriptive cross-sectional web-based study was conducted in Saudi Arabia to assess public knowledge, behavior, and practice toward tattoos and piercings.All individuals over the age of 18 who consented to participate in the study were included in the final analysis.The study excluded individuals who refused to participate, were younger than 18 years old, or spoke a language other than Arabic.The study group was determined by a simple random method.
All participants consented before filling out the survey, and all information was kept completely confidential in accordance with the ethical approval received from the institutional review boards (IRB) for our study.The study investigators created an online questionnaire based on a review of the relevant literature and consultations with two dermatology consultants [6][7][8][9][10][11][12][13].The validity, applicability, and clarity of the questionnaire were evaluated independently by three experts, and all modifications were made to obtain the final version.The survey was prepared in English and translated into Arabic.An Arabic copy was distributed to the participants.Then, the Arabic version was translated back to English by bilingual experts to ensure consistency.
The anonymous questionnaire was published on social media platforms from March 27 to April 10, 2023.Clarifications regarding the extent of confidentiality and the significance of this research to society's health were used to encourage respondents to participate.This study questionnaire included participants' demographic information (age, gender, geographic location, education, occupation, and marital status); knowledge of tattoos and piercings, their associated health effects, and possible infections; attitudes towards tattoos and piercings, assessed using a 5-point Likert scale; and evaluated participants' practice and whether they experienced complications regarding tattooing and body piercing.The final, approved survey was distributed across social media platforms until no more replies were received.
Data were collected and analyzed using the IBM Corp. Released 2012.IBM SPSS Statistics for Windows, Version 21.0.Armonk, NY: IBM Corp.All the statistical methods used were two-tailed with an alpha level of 0.05, and a p-value < 0.05 was considered significant.The overall level of knowledge about tattoos and piercings and the health risks was measured by adding the scores for the different awareness items.If a participant's overall knowledge scores < 60% of the total score were considered a bad level of knowledge, scores ≥ 60% of the total score were considered a good level of knowledge.Frequencies and percentages were used to describe study variables, such as personal information, residence area, and occupation of participants.Participants' knowledge, attitudes, and behavior concerning tattoos and piercings with associated health hazards were tabulated, while overall knowledge and reported adverse health effects and possible infections were presented using plots.Using a Pearson chi-square test for independence and an exact probability measure, slight variations in frequency cross-tabulation were performed to identify factors associated with study participants' awareness of the health hazards associated with tattoos and piercings.

Results
In total, 848 participants completed the survey with a response rate of 98%.Twelve participants refused to complete the survey: 257 (30.3%) were from the western area, 201 (23.7%) were from the central area, 175 (20.9%) were from the eastern area, 111 (13.1%) were from the southern area, and 104 (12.0%) were from the northern area, respectively.The ages of the participants ranged from 18 to over 55 years old, with an average age of 25.2 ± 13.9 years.Regarding the level of education, 570 (67.2%) had a bachelor's degree, 149 (17.6%) had secondary education or less, and 60 (7.1%) had a postgraduate degree.A total of 441 (52%) were students, and 253 (29.8%) were employed (Table 1).

Socio-demographic data
No %    Regarding knowledge of tattoos and piercings among the general population in Saudi Arabia, 336 (39.6%) had an overall good knowledge of tattooing and body piercing hazards (Figure 2).

FIGURE 2: Overall knowledge of tattoos and piercings among the general population in Saudi Arabia
Regarding participants' attitudes towards tattoos and piercings, 779 (91.9%) disliked other body modifications, such as subcutaneous implants and a split tongue; 700 (82.5%) disliked tattoos in general; 683 (80.5%) disliked piercings in places other than the ears; and only 279 (32.9%) disliked ear piercings (Table 3).

TABLE 4: Practices of tattoos and piercings among the general population in Saudi Arabia
Among the factors associated with participants' knowledge of tattoos and piercings, 57 (51.4%) of participants in the southern region had an overall good knowledge of tattoos and piercings and associated health risks versus 26 (25%) of others in the northern region (p = 0.001).Additionally, a higher level of knowledge was observed in females compared to males (42.8% versus 32.4%, p=0.005).Good knowledge was observed among participants with the highest educational level compared to others with diplomas (58.3% versus 14.5%, p = 0.001) (Table 5).Recently, there has been an increase in the frequency of body art usage, accompanied by many hazardous consequences associated with body tattooing and piercing.Tattooing involves injecting ink into the skin to create permanent designs.The process involves puncturing the skin with a needle, which can lead to bleeding, pain, and the risk of infection.Additionally, there is a risk of allergic reactions to the ink or ink pigments [14].Body piercing involves creating a hole in the body to insert jewelry.Piercings can be done on various body parts, including the ears, nose, tongue, nipple, and belly button.The risks associated with body piercing include infection, bleeding, scarring, and allergic reactions to the jewelry material [15].Generally, tattooing and body piercing can be safe if trained professionals adhere to proper hygiene practices.It is essential to be aware of the potential risks and to take appropriate care of the tattoo or piercing to minimize the risk of complications.

Factors
The present study analyzed the public's awareness, attitude, and practice of tattooing and body piercing and their associated health risks.Regarding public knowledge, the survey found that more than one-third of the participants had a decent understanding of body arts and related infections.More than two-thirds of participants knew about adverse health effects or possible infections during body modifications; the vast majority knew that it is risky to undergo piercing or tattooing, and about two-thirds reported that tattoos and piercings transmit infectious diseases.However, very few people believe that the places and tools used for body painting are always safe in terms of health and hygiene.About two-thirds knew it was possible to remove the tattoo, while one-fifth reported that piercing is a permanent practice.Knowledge was significantly higher among some residents in the region, particularly females with high education levels.
Abimbola O et al. [16], in Nigeria, found that 340 (85%) of young adults knew about tattoos and body piercing, and 125 (31.3%) reported fashion as the main reason for body modifications.Bhurtel A and Mudhol [17] reported that 24 (48%) of study adults had high knowledge of tattoos and body piercings, while 17 (34%) had a low knowledge level.A study conducted in Italy among students concluded that males were less knowledgeable about infectious diseases related to body art and that students with piercings were less likely to seek therapy for medical complications [18].Ehwarieme TA et al. [19] found that all university students knew tattoos and body piercings could constitute a health risk.
Considering the health risks and associated complications, this study showed that the most reported health effects and infections were bacterial infections at the body modification site, purpura, cutaneous abscesses, melanoma, HBV, HIV, sepsis, allergic contact dermatitis, and HCV.Ehwarieme TA et al. [19] reported that the most associated health risks and infections included HIV/AIDS, tetanus, hepatitis, pruritus (itching), endorsed skin injury (wound), abscess or boils, inflammation, endorsed damage to underlying blood vessels and nerves, and skin allergies.More than half of the participants in their study said that ongoing infections were a health risk that could result from body piercing or tattooing.Another study on high school students reported a high percentage of health complications following body art procedures.The most common adverse events in tattooed students were skin irritation (30 [19%]) and uncharacteristic bleeding (15 [10.1%]).The most frequent complication associated with body piercing was infection at the site and skin irritation [20].Many people who had piercings or tattoos had not considered the potentially serious health risks and did not know how to check if the procedure followed the appropriate safety requirements [21].
As for participants' attitudes, the current study showed a negative attitude towards tattooing and body piercing, except for ear piercing.The participants disliked other body modifications, such as subcutaneous implants, split tongues, and tattoos, besides their dislike of piercing in locations other than the ears.Miaodong, in his thesis, showed a similar attitude among public participants towards tattooing and body piercing, except for students [22].Schorzman, Gold, Down, and Murry [23] showed that many young adults accept body piercings.Considering public practice for tattooing and body piercing, the current study revealed a considerably low percentage reported undergoing tattooing and body piercing, with only a small percentage considering doing so in the future.This can be explained by the public's acceptable knowledge of the health-related complications and negative attitudes towards these interventions.Among those who underwent tattooing or body piercing, more than half reported that tattooing was done professionally using sterile or disposable instruments with fewer complications.
As this is the first study of its kind conducted in Saudi Arabia, multiple limitations could be addressed in future research.First, data collection was based on a standardized self-administered questionnaire, which may include a selection and recall bias that can affect the results.Second, many cultural variations between the different regions of Saudi Arabia may significantly affect how people perceive body modification and their knowledge about its associated complications.Therefore, more extensive research is necessary to accurately assess the population's overall knowledge regarding these procedures and the health risks they could cause.

Conclusions
This study showed that almost one-third of the participants knew about the health risks and infections related to tattoos and body piercings.Higher awareness was found among females with a high education level.Procedure-related infections were the most common among participants among all associated complications.Most participants showed a negative attitude towards tattooing and body piercing, with a low percentage among those who did tattooing.Moreover, involving family members in the decision-making process was uncommon among those who did tattooing, and they were also informed about the potential risk.Professionals who interact directly with the population should approve appropriate preventive measures.Primarily, older people should be assisted in making informed decisions.Comprehensive educational programs that include inherent risks should also be developed for body artists and encourage young adults to consider their choices carefully beforehand.

FIGURE 1 :
FIGURE 1: Negative health effects and possible infections during body modifications were reported by study participants.HBV: Hepatitis B virus, HIV: Human immunodeficiency virus, HCV: Hepatitis C virus, CMV: Cytomegalovirus.

TABLE 1 : Socio-demographic data of the study participants
The knowledge of tattoos and piercings among the general population in Saudi Arabia as demonstrated in Table2.No %Negative health effects or possible infections during body modifications?