Understanding the hazards of handling and mixing chemicals is essential to safe use. Many of us came to the industry and took up the common uses of customary chemicals in practice, accepting them without much further study. The view that someone else has laid for us our foundation, and a practitioner could simply begin from there is common, but naive. A published record of research and testing by piercers is far too scant. We find a great part of our sources in health and clinical sciences with parallel goals. Applied research provides us with more safety through our broader understanding of how what we choose to use can accomplish a task. There is plenty of motivation to learn firsthand working knowledge of how all the substances we deal with function on the biochemical level. This indicates a need for the dissemination of timely research on the chemicals and combinations that have been used in practice piercing. Getting from point A to point B with the least amount of trouble can be streamlined and simple when we make our decisions based on current and valid research, as opposed to opinions.
Upon first glance, the practical applications of detergent, antiseptic, and disinfectant chemicals appear as straightforward as reading the labels. In the process of learning about what has been commonly used in piercing practice, surprising data relating to a few of these substances indicated a need for further study. Most of us remember that Betadine and Hibiclens may have seemed safe enough for piercing care depending on how you read the bottles. Serious concerns of conscience among piercers who had used those chemicals, and finding safer substitutes with varied degrees of success, changed a great deal about our common practice.
Substances do not always perform as expected or believed in living situations. In most cases, one learns about a thing through scientifically testing its limitations. Many studies demonstrated that BAK (benzalkonium chloride) and BZK (benzethonium chloride) could be ineffective as antiseptics for piercing and care. This presented possibilities for uses or failures that were not apparent in literature provided with the products. Their mildness may be their downfall. The conclusion maintained foremost was that BAK and BZK, as cationic surface active agents, can be neutralized by the alkali or base substances that exist in nearly every kind of soap or shampoo and naturally occur in some skin. The chemical residue may also be irritating, contribute to lumps forming, and accelerate or enable metal dermatitis.
This presents pitfalls when used to clean or prepare skin for piercing, or for aftercare. The long chains of fatty acid molecules that make up surfactants, like BAK and BZK, ideally bond with alkaline substances so that particulate matter on the skin can be rinsed away with water. Most people wash their bodies with some form of sudsy detergent shampoo or soap that changes their skin to a more base or alkaline pH. This renders BAK and BZK inactivated and incapable of providing the antiseptic qualities necessary to adequately degerm skin prior to piercing. Degreasing skin with alcohol does not significantly enable any antiseptic properties, and it makes contact dermatitis more likely. Therefore, their use may be hazardous considering that the surface does not get as clean, and may be more irritated than expected.
The same inactivation occurs when skin is prepared with iodine based antiseptic wiped away with BAK or BZK. Whether done before or after the piercing, it sacrifices the desired protection the skin needs from harmful biological material during and immediately after the procedure. They neutralize each other, leaving PVP-iodine rendered useless as an antiseptic. Without the necessary eight minutes of exposure time prior to breaking the skin, it is less clean than it should be.
If BAK or BZK are used after piercing, any residual antiseptic effect (useful for protection for the short period of time until the piercing seals) is lost, and an irritant coacervate forms. This is an excess of the chemical, bonded to both inorganic and organic material in the coagulum (crust) in the piercing wound site. Contact dermatitis mimicking metal allergy was found as a common result of this buildup. A person could cause thicker, darker colored scars at the site of his or her piercing by following aftercare faithfully using BAK or BZK. If it is the only thing they think is an option often piercees keep on using a chemical, ignoring any reaction unless it hurt them until later stages of hyperplasia set in, and a lump appeared. The microbiological effect of this coacervate, which cannot kill most common germs and even provides nutrition for their breeding, can lead to rapid infection of the wound. Bathing presents other problems. The necessity to rinse thoroughly enough to remove the majority of the detergent residue increases the possibility of infection from Pseudomonas and other organisms (e.g., mold, yeast and fungus) in ordinary tap water because of chemical tissue irritation.
Further study indicates questionable efficacy against a broad enough amount of common germs to be used successfully as antiseptic or anti-infective. This presents dangerous prospects for cross contamination and allergic reaction in the home during aftercare and in practice at the studio if used as a pre-piercing skin preparation. This can lead to infections and reactions, otherwise avoidable.
The simplest practical solution is substitution of a more thorough antiseptic that will not be neutralized in normal use. Sensitive skin preparation as well as aftercare can be effectively achieved by the antiseptic PCMX (para-chloro-meta-xylenol) in three tenths of a percent strength (0.3%, i.e., Provon medicated lotion soap (Gojo) available for personal and professional use). Three percent forms of PCMX (3.0%, i.e., TechniCare (CareTech Laboratories) for professional use) are very effective at the job of skin preparation, but may sting slightly or be irritating to some people with sensitive skin if used for aftercare. Moreover, noting on aftercare instructions for piercees to look for changes in their own skin color or texture at the site will allow them to see the signs protect themselves against contact dermatitis from any cleanser used.
Note: One very inexpensive replacement for both BAK and BZK is sterilized distilled on swabs or gauze to wipe away residue of skin preparative antiseptic. Pre-packaged options available from PDI [and other companies] are inexpensive and pre-sterilized.
Further information will become available in the near future as research on biochemistry continues.
Up to date understanding of the hazards of handling and mixing chemicals is essential to safe use. Assent only should be given tentatively to any scientific information. Even if later it proves to be off base, it seems well founded to reconsider how we deal with chemicals. If we do not have chemistry and microbiology degrees, we can still use the research available to us to our collective advantage. Information does not change, support or negate the efficacy of chemical. It only presents possibilities for uses or failures that were not obvious or available in the literature provided with the products many of us use in our field. It provides us with more safety and a broader scope of understanding how what we do integrates with what we choose to accomplish the task.
No agenda implied or affected, simply make of it what you will. Please add to or adapt this, give public input or use the APP and other educational forums. Questions among piercers have been leveled regarding the uses of these chemicals as antiseptics. The answers found can only be seen as part of the bigger picture.
Re-Evaluating Benzalkonium Chloride Use
Hazards are due to questionable efficacy, microbial contamination and contact dermatitis to coacervate residue on skin.
Benzalkonium chloride (and benzethonium chloride) has been used as an anti-infective, in veterinary medicine as a topical antiseptic, and as a cationic detergent. Cationic detergents have been used agriculturally in herbicides and in antiseptics, spermicides, astringents, germicides, disinfectants, and preservatives. The documented failures outweigh abilities in most uses related to body piercing care and practice.
Shingeharu Oie PhD, Akira Kamiya PhD
Department of Pharmacy, Yamaguchi University Hospital, Ube, Japan.
Microbial contamination of antiseptics and disinfectants.
American Journal of Infection Control 1996 Oct; 24(5): 389-395 (1996)
BACKGROUND: There have been a number of reports on microbial contamination of antiseptics and disinfectants. At present, however, the necessity of measures to prevent contamination do not seem to be fully appreciated. We investigated microbial contamination of antiseptics and disinfectants that are used in our hospital.
METHODS: Fifty-one samples of benzalkonium chloride and chlorhexidine gluconate that were being used in the hospital were examined. Viability of the contaminants detected in these samples was also tested in the agents. Then we examined measures to prevent contamination of these agents.
RESULTS: Microbial contamination was detected at 10(2) to 10(7) CFU/ml in the following samples: 6 of 23 samples of cotton balls soaked in 0.02% benzalkonium chloride kept in a canister for antisepsis and disinfection (26.1%); 7 of 13 samples of 0.02%, benzalkonium chloride or 0.02% chlorhexidine gluconate in an irrigation apparatus kept at 37 degrees C for vaginal douching (53.8%); and 9 of 15 samples of 0.02% benzalkonium chloride or 0.05% chlorhexidine gluconate for storage of suction catheters in a plastic bottle (60%). The major contaminants were Burkholderia cepacia, Pseudomonas aeruginosa, Xanthomonas maltophilia, and Pseudomonas fluorescens. The first two organisms examined grew in the agents. After improvements in the handling of the antiseptics and disinfectants, no microbial contamination was observed.
CONCLUSIONS: It is necessary to check microbial contamination of diluted benzalkonium chloride and diluted chlorhexidine gluconate that are in use. Such products are not recommended as antiseptics.
A piercee who contacts, dilutes or rinses their BAK cleanser with tap water has a high chance of having contaminated the solution and the wound with pathogens such as Pseudomonas aeruginosa.
Benzalkonium chloride: failures as an antiseptic [editorial].
JAMA 1976; 236(21), 2433 (1976)
Nosocomial pseudobacteremia. Positive blood cultures due to contaminated benzalkonium antiseptic.
JAMA 1976; 236(21), 2407-2409 (1976)
MJ Frank, W Schaffner
Contaminated aqueous benzalkonium chloride. An unnecessary hospital infection hazard.
JAMA 1976 Nov 22; 236(21): 2418-2419 (1976)
During January and February 1975, nine patients on a single ward of a rural Tennessee hospital unexpectedly developed sepsis. The aseptic technique employed in the management of intravenous infusions was implicated. Pseudomonas cepacia was recovered from the following: bloodstream, inuse intravenous infusions and the antiseptic, aqueous benzalkonium chloride. The outbreak again calls attention to the infection risk associated with the use of this product. Selection of less hazardous antiseptics and disinfectants is strongly recommended.
BAK kills an inadequate spectrum of germs, allowing particularly popular strains in our environment a chance to contaminate the wound. Choosing another germicide to prepare skin for piercing could prevent infections such as in this case.
Jeff and Rene’ Martin of Rites of Ascension had this excerpt to add:
According to the Environmental Protection Agency (EPA), Pseudomonas are present in most water systems in the United States. Although the concentration varies geographically, this poses a disturbing problem: Benzalkonium chloride can become contaminated with Pseudomonas during a piercee’s aftercare regimen, resulting in rapid infestation of pathogenic material.
“…Most Pseudomonas species, including P. aeruginosa have relatively simple nutritional requirements and can replicate in medicinal solutions such as procaine and benzalkonium chloride…”
Saunders W.B. Co.
The Biologic and Clinical Basis of INFECTIOUS DISEASE
Northwestern University Medical School, Chicago, Illinois 1975; 706 (1975)
“…These organisms are frequently found in hospital solutions that have been allowed to stand for a long time, such as benzalkonium chloride, hexachlorophene soap, saline solution, penicillin, water in flower vases, and fluids in incubators, humidifiers, and respiratory therapy equipment…”
Handbook of Diseases 1996; 704 (1996)
What are Pseudomonas?
Pseudomonas are small gram negative (airborne) bacteria which can cause infections and disease in various parts of the body. In advanced stages, Pseudomonas infections can be life-threatening disorders, although localized infections are highly curable.
What do Pseudomonas infections look like?
Drainage in Pseudomonas infections are distinct, they have a sickly sweet odor and a blue-green pus that forms crusts on wounds. Other symptoms vary greatly depending on the site of the infection.
What can possibly happen if a Pseudomonas infection occurs?
P. aeruginosa has the ability to invade the endothelial cell lining of major blood vessels. Further development can cause vasculitis (inflammation and necrosis of blood vessels) and thrombosis (clotting in renal veins), and can serve as a source for continued re-entry of the microorganism into the circulation.
The most common infections associated with Pseudomonas include skin infections, urinary tract infections, diarrheal illnesses, bronchitis, pneumonia, bronchiectasis (destruction of bronchial walls), meningitis, corneal ulcers, mastoiditis (infection and inflammation of inner ear air cells, can lead to hearing loss), otitis external (inflammation of skin of inner ear canal, “swimmer’s ear”), otitis media (inflammation of inner ear, can lead to deafness, endocarditis (infection of endocardium and heart valves) and bacteremia.
The research clearly states that contamination is not only possible, but highly probable without strict adherence to proper handling.
Contact Dermatitis Magazine Database:
Merck Index Number 1066
Chemical Abstract Service Registry Number 8001-54-5
Benzalkonium chloride is composed of a mixture of alkyldimethylbenzylammonium chlorides of the general formula in which R represents a mixture of the alkyls from C8H17 to C18H37. It functions as a cationic surface-active agent, germicide, preservative, and antiseptic.
Benirol, Benzalkonium chloride, Bradophen, BTC, Cequartyl, Drapolene, Dropolex, Enuclene, Germitol, Gesminol, Osuan, Paralkan, Roccal, Rodalon, Zephiran, Zephiran chloride
- Agriculture, fabric, dye, and metallurgy industries
- Cold sterilization solution for medical and dental instruments
- Contact lens solutions
- Cosmetics, shampoos, and deodorants
- Eye solutions and medications
- Injectable medications
- Mouthwash, lozenges, and medications for the mouth and throat
- Skin cleansers
- Skin creams and medications
- Udder wash
Cetrimonium bromide, Benzethonium chloride
Toxicology and Carcinogenesis Studies of Benzethonium Chloride (CAS No. 121-54-0) in F344/N Rats and B6C3F1 Mice
National Institute of Health Toxicology Report-438
Chemical Formula: C27H42NO2 Cl
Synonyms: Benzyldimethyl-p-(1,1,3,3-tetramethylbutyl) phenoxyethoxy-ethylammonium chloride; diisobutylphenoxyethoxyethyldimethyl benzyl ammonium chloride; p-tert-octylphenoxyethoxyethyldimethylbenzyl ammonium chloride
Trade names: Anti-germ 77, Antiseptol, BZT, Diapp, Disilyn, Hyamine, Hyamine 1622, Phemeride, Phemithyn, Polymine D, Quatrachlor, Solamine
Benzethonium chloride is used primarily in cosmetics for its antimicrobial and cationic surfactant properties. Benzethonium chloride was nominated by the National Cancer Institute to the NTP for study from a class study of chemicals used as biocides. The chemical was selected based on a suspicion of carcinogenicity and its known widespread human exposure. Male and female F344/N rats and B6C3F1 mice were topically administered benzethonium chloride (greater than 98% pure) for 16 days, 13 weeks, or 2 years.
16-DAY STUDY IN RATS
Groups of five male and five female F344/N rats were topically administered 0, 6.3, 12.5, 25, 50, or 100 mg benzethonium chloride/kg body weight. Rats were administered a total of 12 doses in a fixed volume of 250 µL ethanol. All rats survived to the end of the study. The final mean body weights and body weight gains of rats administered 50 or 100 mg benzethonium chloride/kg body weight were significantly less than those of the controls. Clinical findings at necropsy included thickening or hardening of the skin at the site of application in all rats administered 50 or 100 mg/kg and in 25 mg/kg males. Lesions at the site of application appeared crusty or red-grey in color. Epithelial hyperplasia with or without inflammation occurred at the site of application in all groups of males and females administered benzethonium chloride.
Even in the shortest studies, tissue irritation and damage took place that greatened as the length of the studies did. Epithelial hyperplasia occurred in all groups, even when the chemical was diluted farther with each longer study. Hyperplasia refers to a non-cancerous tumor-like overgrowth of excess cells. As piercers, we see the results of this often. No carcinogenic evidence was found by the study.
OTC Options: Help for Cuts, Scrapes and Burns
FDA Consumer magazine (May 1996) http://www.fda.gov/fdac/features/496_cuts.html
Because topical antimicrobials are not totally effective in killing bacteria, FDA does not allow firms to place the claim “Helps kill bacteria” in the same area as the required information. FDA believes the term “kill” implies the product will eliminate all bacteria and could be misleading if appearing with the required term “infection” (or alternate term “bacterial contamination”) in the label’s indications section. The claim may be used, though, as additional information elsewhere in the label.
In its proposed rule, FDA listed these active antiseptic ingredients as tentatively safe and effective: ethyl alcohol (48 to 95 percent), isopropyl alcohol, benzalkonium chloride, benzethonium chloride, camphorated metacresol, camphorated phenol, phenol, hexylresorcinol, hydrogen peroxide solution, iodine tincture, iodine topical solution, povidone-iodine, and methylbenzethonium. Five ingredients listed as tentatively effective only in combination products are ethyl alcohol (26.9 percent), eucalyptol, menthol, methyl salicylate, and thymol.
“The drugs can be hard on the skin,” says Debbie Lumpkins, a microbiologist in FDA’s division of OTC drug evaluation. She explains that, “when bandaged, the skin gets damp, increasing absorption. Therefore, more drug enters the skin and may cause more damage than if you just left the wound uncovered.”
Comments on the proposal were minimal, Lumpkins says, emphasizing that FDA’s evaluation of the ingredients is still very much an evolving process.
Recent publications advise against two currently marketed antiseptics. The National Safety Council’s 1996 First Aid Pocket Guide states: “DO NOT use hydrogen peroxide. It does not kill bacteria, and it adversely affects capillary blood flow and wound healing.” And the Handbook on Nonprescription Drugs states ethyl alcohol “is not a desirable wound antiseptic because it irritates already damaged tissue. The coagulum [crust] formed may, in fact, protect the bacteria.”
The final rule will reflect FDA’s evaluation of all the data, Lumpkins says. Thus, antiseptic ingredients proposed as safe and effective could be found unsafe or ineffective, or new ingredients could be added, depending on new information.
Whether using an OTC antibiotic or antiseptic, consumers should realize “there are limits to what the products can do,” Lumpkins says. “People should read the label, and use the product appropriately. If they notice a change in their condition, or if there’s redness or swelling, they shouldn’t continue to try to treat it. They should see a doctor.”
The FDA asserts that antiseptic products are presently still under review. Bactine ©, Sensitive Ear Care © and the like and may be proven ineffective.
Shah D, 1973
Coacervate formation by inorganic salts with benzalkonium chloride.
J Pharm Sci 62(10), 1741-1742 (1973)
Shah D, 1973
Coacervate formation by sodium salicylate with benzalkonium chloride.
J Pharm Sci 62(7), 1210 (1973)
Jono K, 1986
Effect of alkyl chain length of benzalkonium chloride on the bactericidal activity and binding to organic materials.
Chem Pharm Bull (Tokyo) 34(10), 4215-4224 (1986)
The BAK chemical residue left in the skin and crust formed by a piercing can allow pathogens to live and reproduce, increasing the risk of infections and allergic reactions. Moreover, BAK bonds with alkyl chemicals on the skin, which reduces its ability to kill pathogens.
el-Nakeeb MA, 1974
Relationship between the physical and microbiological incompatibilities of benzalkonium chloride and sodium lauryl sulphate.
Pharmazie 29(1), 61-62 (1974)
Cremieux A, 1982
Inhibition of the bactericidal activity of polyvinylpyrrolidone-iodine and benzalkonium chloride by nonionic and ampholytic surfactants
J Pharm Belg 37(4), 263-266 (1982)
Soap residues on skin left from ordinary bathing can make BAK even more ineffective because they are incompatible chemicals.
This can aggravate and or enable stronger allergic reactions.
Contact dermatitis caused by benzalkonium chloride mimicking metal dermatitis
G Ital Dermatol Venereol 123(10), 513-515 (1988)
Other possible reactions to BAK include similar symptoms to metal contact dermatitis.
Worksafe Western Australia (1996) offers a clear description for common symptoms of contact dermatitis.
DERMATITIS simply means inflammation of the skin.
What is Contact Dermatitis? Contact Dermatitis is an inflammation that occurs when a substance comes into contact with skin. The skin is irritated and there is an abnormal reaction.
How does the skin react? Areas of irritated skin may be red, swollen, tender, hot, painful or itchy. If the reaction is severe, the skin may blister or weep and can become crusty. There may be some scaling as the skin heals. Skin affected for several weeks by dermatitis tends to thicken and change to a deeper colour. Sometimes there may be a reaction only when direct sunlight and an irritating substance are on the skin at the same time. This kind of contact dermatitis looks a lot like sunburn. Scratching or rubbing itchy skin can make dermatitis symptoms worse.
How long after contact will dermatitis develop? Some irritating substances will have an immediate and obvious effect on the skin. Other substances could be used regularly for a long time before the skin begins to react. After the first reaction occurs, dermatitis will develop fairly quickly each time there is contact with that substance.
A person could cause thicker, darker colored scars at the site of his or her piercing by following aftercare faithfully using BAK. How often do piercees tell us they guessed that kind of reaction was normal until the later stages of hyperplasia set in, and a lump had appeared? We can avoid this by substituting a mild antibacterial soap as suggested care. Moreover, noting on aftercare instructions for piercees to look for changes in their own skin color or texture at the site will allow them to see the signs protect themselves against contact dermatitis from any cleanser used.
Benzalkonium chloride (BAK) and the chemical with similar properties, benzethonium chloride (BZK), had been suggested by the APP both for piercing aftercare and as an alternative for skin site preparation for piercing. Further study indicates questionable efficacy against a broad enough amount of common germs to be used as antiseptic. Also, a harmful coacervate forms; an excess of the chemical, bonded to both inorganic and organic material in the coagulum (crust) in the piercing wound site. Contact dermatitis was found as a common result of this buildup. The microbiological effect of this coacervate, which cannot kill some common germs and allows them to breed, can lead to rapid infection of the wound by pathogens.
This presents dangerous prospects for cross contamination and allergic reaction in the home during aftercare and in practice at the studio if used as a pre-piercing skin preparation. This can lead to infections and reactions, otherwise avoidable.
Cautions suggested include mild antibacterial soap as an alternative for care and a less hazardous chloroxylenol (PCMX) antibacterial agent for skin preparation. For example, Care-Tech Labs manufacture[d] TechniCare for pre-op, post-op and IV site maintenance available in 12mL tubes that could be used for disposable prep packs. It contains 3.0% PCMX. Gojo manufactures a comparable version of Provon for similar purposes and another for aftercare and handwashing containing a smaller amount 0.3% PCMX with triclosan, the antibacterial ingredient in many popular liquid soaps such as Dial ©.