• Users Online: 504
  • Print this page
  • Email this page

Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 182-187

Cartilage ear piercing probable infections among females between 18 and 28 years old in Riyadh

1 Department of Pathology, College of Medicine; King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
2 College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission18-Aug-2021
Date of Decision15-Jan-2022
Date of Acceptance24-Feb-2022
Date of Web Publication28-Apr-2022

Correspondence Address:
Khalifa Binkhamis
Department of Pathology, College of Medicine, King Saud University, Riyadh
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_108_21

Rights and Permissions

Background: The prevalence of ear piercings is 8%−32%. Complications can be due to the factors such as the amount of tissue blood supply, the location of the piercing, the extent of hygiene techniques, and much more. Materials and Methods: A total of 586 females (age, 18–28 years) in Riyadh, Saudi Arabia, with at least one ear piercing were included in this analytical cross-sectional study by convenience sampling from September 2019 to April 2020. A link to an Arabic web-based questionnaire was distributed through social media (WhatsApp, Twitter, and Snapchat). It included questions related to both earlobe and ear cartilage piercings. Bivariate statistical tests were carried out. Results: The prevalence of a probable ear piercing-related infection for ear cartilage piercings was found to be significantly higher than for earlobe piercings (41.4% vs. 29.6%) (P = 0.0004) (confidence interval [CI] = 0.443–0.795). A significant association between piercing type (3.3% of earlobe piercings and 8.1% of ear cartilage piercings) and scar formation was observed (P = 0.0002) (CI = 0.209–0.722). The prevalence of ear piercing complications among participants who used piercing needles was lower for both earlobe piercings and ear cartilage piercings (3.65%, 8.75%) (P = 0.0015) than among those who used piercing guns (37.9%, 43.4%) (P = 0.114). Conclusion: Probable external ear infections were more common among those with cartilage ear piercings than those with earlobe piercings. Future studies should include participants of a broader age category and in different locations in Saudi Arabia.

Keywords: Auricle, cartilage, chondritis, complication, ear, earlobe, infection, perichondritis, piercing, pinna

How to cite this article:
Binkhamis K, Habib HA, Alkahtani MK, Alrasheed DA, Barakeh MM, Alohali LM, Aloqayfi SI. Cartilage ear piercing probable infections among females between 18 and 28 years old in Riyadh. J Nat Sci Med 2022;5:182-7

How to cite this URL:
Binkhamis K, Habib HA, Alkahtani MK, Alrasheed DA, Barakeh MM, Alohali LM, Aloqayfi SI. Cartilage ear piercing probable infections among females between 18 and 28 years old in Riyadh. J Nat Sci Med [serial online] 2022 [cited 2022 May 21];5:182-7. Available from: https://www.jnsmonline.org/text.asp?2022/5/2/182/344199

  Introduction Top

Body piercings have been used worldwide for centuries. Despite being a common practice, the prevalence of associated complications is relatively high (30%).[1],[2],[3],[4],[5],[6],[7] Among all complications, localized infections are the most common (77%).[1],[7],[8] It was estimated that localized infections occur in approximately 20% of body piercings.[1],[9] The most common pathogens include Staphylococcus aureus and Group A Streptococcus for lobular ear piercings and Pseudomonas aeruginosa for cartilage ear piercings.[8],[9],[10] The symptoms of ear piercing infections include erythema, pain, or oozing blood and pus.[9],[10]

It is estimated that between 8% and 50% of the population in Quebec, Canada, and the United states have body piercings.[2],[3] In a study in Birmingham, UK, the highest prevalence of body piercings was among college students and young adults, with the ears being the most commonly pierced site.[4] Although earlobe piercings are popular, other body piercing sites have emerged.[5] A study in England showed that ear piercings located in zones other than the lobular zone represent the third-most common body piercing, with a prevalence of 13%, preceded only by navel piercings (33%) and nose piercings (19%).[6] Body piercings are more common among females than males, and the prevalence is higher among 16–25 years old individuals,[11] with a marked fall in prevalence by increasing age.[4],[6] Interestingly, it has been shown that both cultural background and economic status have an impact on the prevalence of body piercings. In Nigeria, for example, ear piercing is performed on 37.2% of the infants within the first week of birth for beautification and female-sex identification purposes.[12] Several studies have shown that the prevalence of body piercings in developed countries ranges from 4.3% to 51%.[13],[14],[15],[16],[17],[18]

Various methods are used for piercing, and these are broadly categorized into professional and unprofessional methods.[4] The professional method involves the use of a sharp, hollow, 14–16-gage needle.[4] Unprofessional methods may involve everything from household equipment to piercing guns, which are difficult to clean and sterilize.[4] Most piercings are performed using a piercing gun; in a study performed in the United States of America, 60% of the study participants pierced their ears using piercing guns.[7] Ear piercing complications may be attributed to the piercing method as piercing needles are disposable; therefore, complications are less compared to piercing guns which are reusable and more challenging to clean.[19]

In addition, other drastic complications are associated with ear piercings such as abscesses, sepsis, allergies, keloid, or ear deformities.[20],[21] In a study in Poland, the most commonly identified ear piercing-associated complications were keloids and tearing after trauma.[22] Several factors contribute to the development of complications, including the zone of the piercing, who performed the piercing, the instrument used for piercing, and the use of aftercare solutions.[4] For instance, cartilage ear piercings, particularly helix piercings are associated with a >250-fold increased risk of infection due to the lack of vascularity of the cartilage.[4],[20]

The study's essence was to address several factors that may contribute to the development of ear piercing infections as suggested by other studies.[4],[19] Hence, the primary aim of this study was to compare the proportion of probable external ear infections associated with cartilage ear piercings to the proportion of probable external ear infections associated with lobular ear piercings. Furthermore, the association between the method of piercing and related complications was also studied. According to the data obtained from a study that compared between cartilage and soft tissue ear piercing complications, we hypothesized that there is a 9% increase in the prevalence of probable external ear infections in cartilage ear piercings in comparison to lobular ear piercings.[7]

  Materials and Methods Top

The study was performed in Riyadh, Saudi Arabia from September 2019 to April 2020. Females between the ages of 18 and 28 years old with at least one piercing were asked to take part in this analytical cross-sectional study. The study compared two types of ear piercings; earlobe and ear cartilage piercings. The sample size was calculated using the following formula: n = (Zα + Zβ) ([p1 + q1] + [p2 + q2])/(p1 − p2) 2, where Zα = 1.96 for 95% confidence level and Zβ = 1.282 for 90% power. The values of P and q were similar to those used in a previous study;[18] p1 = 0.30, q1 = 0.7, p2 = 0.21, and q2 = 0.79. Based on the calculation, the sample size was determined to 488 participants. To allow for a certain nonresponse rate, 20% was added to the original sample size (488) yielding a total sample size of 586 participants (n = 586).

A web-based questionnaire was designed by the researchers of the study.[6],[7],[23],[24] The inclusion criteria were as follows: Females between 18 and 28, living in Riyadh, Saudi Arabia with at least one piercing. Males were excluded from the criteria, as well as females with no ear piercings. Following that, the questionnaire was evaluated by three consultants in relevant fields (family medicine, infectious disease, and otolaryngology). Those specialties were consulted as experts in the field who encounter similar cases. These consultants evaluated the level of difficulty, appropriateness, and ambiguity of the phrases in the questionnaire. Moreover, they evaluated the questionnaire regarding its usefulness in providing the needed information to assess the probability of infection. Moreover, the questionnaire was adjusted based on their recommendations. It included 33 questions, which were translated to the participant's native language; Arabic. At the beginning of the questionnaire, an informed consent was included, which provided information on the goals and purposes of the study. Moreover, it emphasized that the participation was utterly unforced with protected autonomy and confidentiality, and participants had the complete right to stop whenever they would wish to do so. Next, demographic questions and specific questions related to both earlobe and ear cartilage piercings were included to cover all desired study variables, including nationality, residence city, age, comorbidities, piercing zone and number of piercings, who performed the piercing, instrument used for piercing, use of aftercare solution, complications, and the management of these. In order for participants to properly allocate their ear piercings, the questionnaire included an ear picture that clearly demarcated both lobular and cartilages area. After approval from the institutional review board at the college of medicine, King Saud University (Project No. E-19-4441) on the December 8, 2019, a pilot study on 59 participants was conducted. The pilot study helped tackle all dilemmas related to the understanding and relevance of the questions as well as approximating the time required to answer the questions. The participants were sampled by convenience sampling, and the questionnaire was distributed through social media; WhatsApp, Twitter, and Snapchat. The primary objective was to compare the proportion of probable external ear infection for cartilage ear piercings and lobular ear piercings, respectively.

Despite the fact that ear piercings infections are common,[7] 50% of patients do not seek medical advice and only 1% get admitted.[1] Moreover, most ear piercings infections are diagnosed clinically and treated empirically.[7] Therefore, utilizing a microbiological or histological diagnosis may underestimate the prevalence. Hence, a diagnostic criteria were established based on the literature.[7],[24],[25] and the consensus of three consultant physicians. The diagnostic criteria of the study were that participants with fever possibly had infection, whereas participants with any of the following signs and characteristics probably had an infection: Edema, painful hyperemia, abscess, symptom occurring a few hours to 3 days post piercing, or cauliflower deformity. There were potential sources of biases, the questionnaire was web based so the participants might have had a recall bias. Another source of bias was cultural bias, due to the exclusion of males from our criteria because it is culturally not acceptable for males to have piercings. There is also a potential measurement bias as regards to infection symptoms, as the survey does not include all symptoms of probable ear infection, and some symptoms could overlap with other diseases.

The sample size was fulfilled after a period of 1 month and collected data were subject to analysis using the statistical software SPSS v. 25.0 (IBM, Armonk, New York, USA). Descriptive statistics (frequencies and percentages) were used for the quantitative and categorical variables. Bivariate statistical tests were carried out (mainly Chi-square test, with the Fisher exact test used for values <5). 95% confidence interval (CI) were reported and a statistical significance level was considered at a P value of 0.05.

  Results Top

A total of 581 females with ear piercings were included in the study. Participants were classified based on the location of the piercings as earlobe and ear cartilage piercings. Females with no ear piercings were excluded. Most of the participants were Saudis. Ear piercings are seen more in younger females. The prevalence of participants with earlobe piercings only and participants with both earlobe and ear cartilage piercings were approximately similar (48.9% and 50%, respectively). Piercings were performed mainly by a nurse or a physician. Demographic data and ear piercing-related variables are shown in [Table 1] (Note that [both] column indicates participants who have had both ear lobe and ear cartilage piercings).
Table 1: Demographic characteristics and piercings related variables of participants

Click here to view

In [Table 2], [Table 3], [Table 4], [Table 5], participant piercing events were classified depending on the piercing zone into earlobe piercings (zone A, n = 575) and ear cartilage piercings (zone B, n = 297). The symptoms related to ear piercing infection are listed in [Table 2]. The majority of both Zone A (48.0%) and Zone B (62.6%) were associated with more than one of these symptoms (P < 0.001; 95% CI, 0.414–0.734). Among individuals with one symptom only, the most common symptom was pain (4.5%) in Zone A, whereas in Zone B, pain and redness were reported with similar frequency (5.05%) (P = 0.729).
Table 2: Ear piercing infection symptoms associated with Zone A (piercings in earlobe) and Zone B (piercings in ear cartilage)

Click here to view
Table 3: Complications of ear piercing in Zone A (earlobe) and Zone B (ear cartilage)

Click here to view
Table 4: Prevalence of ear piercing complications based on the method of piercing

Click here to view
Table 5: Probable ear piercing infections between Zone A (earlobe) and Zone B (ear cartilage)

Click here to view

The complications associated with the piercings are listed in [Table 3]. The most common complication was scar formation (3.3%, 8.1% for zones A and B, respectively; P = 0.002), and the least common was tear of the skin with the need of surgery (0.5%, 1.01% for zones A and B, respectively; P = 0.256). There was a statistically significant association between piercings and scar formation (P = 0.0002, CI = 0.209–0.722). The prevalence of abscess formation was approximately similar for both zones (1.9%, 1.35% for Zones A and B, respectively; P = 0.543).

The prevalence of ear piercing complications based on the method of piercing is shown in [Table 4]. Furthermore, the difference in the prevalence of ear piercings complications among participants who used piercing guns as the piercing instrument of choice was statistically insignificant (37.9%, 43.4%) for zones A and B respectively (P = 0.114). However, participants who used piercing needles showed a much lower prevalence of ear piercing complications for Zone A in comparison to Zone B (3.65%, 8.75%), respectively, which was statistically significant (P = 0.0015). Overall, the prevalence of ear piercing complications among participants who used piercing needles was lower in both Zones A and B in comparison to piercing guns

In [Table 5], the prevalence rates of probable piercing-related infections in Zone A (29.6%) and B (41.4%) differed with statistical significance (P = 0.0004) (CI = 0.443–0.795), and so, the prevalence of probable piercing-related infection in Zone B was higher than Zone A. No participants were classified as having a possible ear piercing-related infection

  Discussion Top

In this study, the prevalence among participants with earlobe piercings only and with both earlobe and ear cartilage piercings were approximately similar (48.9% and 50%). The individuals with the highest rate of piercings observed were those aged 20–21 years old, which is consistent with other studies that noted a marked decrease in piercing prevalence with increasing age.[3],[4] Most of the piercings were performed by a physician/nurse, which differs from that in the study by Simplot and Hoffman who found that 49% of the piercings were carried out by a department store employee, whereas only 14% were carried out by a physician.[7] Meanwhile, a study in England saw 80% of piercings being performed by piercing and tattoo specialists.[6]

Almost 80% of the participants used aftercare solution, which is in agreement with the findings of another study in which all individuals with ear piercings infections had used aftercare solution, a finding that suggested that the use of aftercare solutions may be a risk factor for developing piercing-related infections if these solutions were contaminated.[26]

Although most of the participants had more than one of the following symptoms: pain, itching, painful redness, swelling, edema, skin warmth, fever, abscess, and hearing loss; pain was the most common symptom that appeared alone for both Zone A and Zone B piercings (4.52% and 5.05%, respectively). This is in contrast to a study performed in London, UK, which showed that perichondritis was the most common complication of ear cartilage piercing.[21]

This study found a significant association between probable ear infection and having both lobular and cartilage ear piercings. Nevertheless, most of the participants had no complications for both zones A and B (57.39% and 46.46%, respectively). The prevalence of probable infection was higher for zone B piercings (41.41%) than for zone A piercings (29.57%). The previous results go in hand with another study that had mentioned that earlobe piercings are safer than ear cartilage piercings.[27] The results were relatively different from Simplot and Hoffman's study, which identified ear cartilage-related infections in 30% of the study individuals.[7]

The most important risk factors of ear piercing infections are those that affect the healing time, the adequacy of blood supply, and the integrity of the tissue.[4] Hence, the limited presence of vasculature in cartilage tissue explains why infections would be prone to developing in this area. Regardless of the insignificant result of the prevalence of ear piercing complications from using a piercing gun, the prevalence of complications in those who had used a piercing needle was lower; in Simplot and Hoffman's study, only a minimal difference was observed between these two methods.[7]

The findings of this study have to be considered in light of some limitations. The first limitation was the use of a convenience sampling. Convenience sampling was used to be able to complete the study on a sufficient number of participants in a cost- and time-effective manner. A second limitation was that the study was carried out in Riyadh and limited to the female gender only due to cultural reasons. The third limitation was that the ear piercing infection was not diagnosed clinically by a physician. Instead, it was based on criteria established by three physicians. Given this limitation we were only able to classify the infections into probable, possible or unlikely.

The clinical relevance of our research is widespread. We suggest that physicians and other relevant health-care providers educate patients and the public on ear piercing infections, the different approaches to piercings, associated risks and complications. This would help raise awareness with regard to safer methods and locations for piercing with minimal infection risks. It is important to raise the awareness since a delay in seeking treatment could lead to systemic manifestations and complications.[27]

  conclusion Top

In conclusion, probable external ear infection was found more among individuals with cartilage ear piercings than those with lobular ear piercings. A common complication in both piercing zones was scar formation. The rate of ear piercing complications among participants who used piercing needles was lower in both earlobe piercings and ear cartilage piercings than in those using piercing guns. In view of the remarkable popularity of piercings, especially among teenagers, and the scarcity of related studies, it is recommended to carry out studies targeting broader age categories in different locations in Saudi Arabia. To eliminate the cultural bias, further research in different countries is suggested.

Ethical approval

This study was approved by the King Saud University Institutional review board (Research ID: E-19-4441). The approval date was on December 8, 2019.


We would like to thank the Deanship of Scientific Research and RSSU at King Saud University for their technical support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Holbrook J, Minocha J, Laumann A. Body piercing: Complications and prevention of health risks. Am J Clin Dermatol 2012;13:1-17.  Back to cited text no. 1
Deschesnes M, Finès P, Demers S. Are tattooing and body piercing indicators of risk-taking behaviours among high school students? J Adolesc 2006;29:379-93.  Back to cited text no. 2
Laumann AE, Derick AJ. Tattoos and body piercings in the United States: A national data set. J Am Acad Dermatol 2006;55:413-21.  Back to cited text no. 3
Patel M, Cobbs CG. Infections from body piercing and tattoos. Microbiol Spectr 2015;3:1-13. [doi: 10.1128/microbiolspec.IOL5-0016-2015].  Back to cited text no. 4
Fijałkowska M, Pisera P, Kasielska A, Antoszewski B. Should we say NO to body piercing in children? Complications after ear piercing in children. Int J Dermatol 2011;50:467-9.  Back to cited text no. 5
Bone A, Ncube F, Nichols T, Noah ND. Body piercing in England: A survey of piercing at sites other than earlobe. BMJ 2008;336:1426-8.  Back to cited text no. 6
Simplot TC, Hoffman HT. Comparison between cartilage and soft tissue ear piercing complications. Am J Otolaryngol 1998;19:305-10.  Back to cited text no. 7
Guiard-Schmid JB, Picard H, Slama L, Maslo C, Amiel C, Pialoux G, et al. Piercing and its infectious complications. A public health issue in France. Presse Med 2000;29:1948-56.  Back to cited text no. 8
Van Hoover C, Rademayer CA, Farley CL. Body piercing: Motivations and implications for health. J Midwifery Womens Health 2017;62:521-30.  Back to cited text no. 9
Pena FM, Sueth DM, Tinoco MI, Machado JF, Tinoco LE. Auricular perichondritis by piercing complicated with pseudomonas infection. Braz J Otorhinolaryngol 2006;72:717.  Back to cited text no. 10
Perry M, Lewis H, Thomas DR, Mason B, Richardson G. Need for improved public health protection of young people wanting body piercing: Evidence from a look-back exercise at a piercing and tattooing premises with poor hygiene practices, Wales (UK) 2015. Epidemiol Infect 2018;146:1177-83.  Back to cited text no. 11
Gabriel OT, Anthony OO, Paul EA, Ayodele SO. Trends and complications of ear piercing among selected Nigerian population. J Family Med Prim Care 2017;6:517-21.  Back to cited text no. 12
[PUBMED]  [Full text]  
Armstrong ML, Roberts AE, Owen DC, Koch JR. Contemporary college students and body piercing. J Adolesc Health 2004;35:58-61.  Back to cited text no. 13
Roberts TA, Auinger P, Ryan SA. Body piercing and high-risk behavior in adolescents. J Adolesc Health 2004;34:224-9.  Back to cited text no. 14
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.  Back to cited text no. 15
Willmott FE. Body piercing: Lifestyle indicator or fashion accessory? Int J STD AIDS 2001;12:358-60.  Back to cited text no. 16
Brooks TL, Woods ER, Knight JR, Shrier LA. Body modification and substance use in adolescents: Is there a link? J Adolesc Health 2003;32:44-9.  Back to cited text no. 17
Carroll ST, Riffenburgh RH, Roberts TA, Myhre EB. Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Pediatrics 2002;109:1021-7.  Back to cited text no. 18
More DR, Seidel JS, Bryan PA. Ear-piercing techniques as a cause of auricular chondritis. Pediatr Emerg Care 1999;15:189-92.  Back to cited text no. 19
Preslar D, Borger J. Body Piercing Infections. In: StatPearls [Internet]. Treasure Island (FL, USA): StatPearls Publishing; 2019 Jan .  Back to cited text no. 20
Mandavia R, Kapoor K, Ouyang J, Osmani H. Evaluating ear cartilage piercing practices in London, UK. J Laryngol Otol 2014;128:508-11.  Back to cited text no. 21
Fijałkowska M, Kasielska A, Antoszewski B. Variety of complications after auricle piercing. Int J Dermatol 2014;53:952-5.  Back to cited text no. 22
Ear Piercing Guide & Chart. Tulsa Body Jewelry; 2019. Available from: https://www.tulsabodyjewelry.com/blogs/news/ear-piercing-guide-chart. [Last accessed on 2019 Oct 27].  Back to cited text no. 23
Wiegand S, Berner R, Schneider A, Lundershausen E, Dietz A. Otitis externa: Investigation and evidence-based treatment. Deutsch Ärztebl Int 2019;116:224.  Back to cited text no. 24
Keene WE, Markum AC, Samadpour M. Outbreak of Pseudomonas aeruginosa infections caused by commercial piercing of upper ear cartilage. JAMA 2004;291:981-5.  Back to cited text no. 25
Fisher CG, Kacica MA, Bennett NM. Risk factors for cartilage infections of the ear. Am J Prev Med 2005;29:204-9.  Back to cited text no. 26
Sosin M, Weissler JM, Pulcrano M, Rodriguez ED. Transcartilaginous ear piercing and infectious complications: A systematic review and critical analysis of outcomes. Laryngoscope 2015;125:1827-34.  Back to cited text no. 27


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


    Similar in PUBMED
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Materials and Me...
Materials and Me...
Article Tables

 Article Access Statistics
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal