About the CIEH Guidelines

In 2001 Barbour index PLC published a set of best practice guidelines for Body Art, Cosmetic Therapies and other special treatments on behalf of the Chartered Institute of Environmental Health.

This rather rambling tome is a little difficult to understand because it covers not just tattooing and piercing. It also covers :

The information in this book is intended for use by adequately qualified, trained and experienced people acting under appropriate supervision, so it's unlikely that you will ever get the chance to peruse a copy, even though all piercing studios in Britain should have this publication on their premises.

As this book is 134 pages long I won't attempt to reproduce it word for word. I'm just going to deal with the basics and divide the information into sections to try to make it easier to understand.

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The law regarding body art procedures

"There is no legislation in force that pertains purely to skin piercing activities, although there are usually 2 areas of legislation available to local authorities. These are:

London also has the "London Local Authorities act 1991" which is only applicable within the London Boroughs.Many local authorities have local licensing legislation that applies to their particular area. Birmingham has powers under the "Birmingham City Council act 1990" and Nottingham City Council also has powers under it's own local authority act.

The "Health and Safety at work act 1974" is the legislation used by local authorities to ensure that health and safety standards are maintained "SO FAR AS IS REASONABLY PRACTICABLE" in commercial premises, but doesn't apply to those piercers working out of their homes.

Section 3 of this act states "It is the duty of every employer or self employed person to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that he and other persons who may be affected are not exposed to risks to their health or safety".

The "Local Government (Miscellaneous Provisions) act 1982" allows local authorities to register both the person carrying out skin piercing activities (Acupuncture, Electrolysis and Ear Piercing) and their premises. There is no power for local authorities to refuse to register piercers (which means if you register as a piercer they have to let you register even if they know you're not capable) and the registration remains in force until the practitioner closes the business or a magistrates court cancels the registration.

Other legal issues

Civil law imposes a "Duty of Care" to safeguard the health, safety and well being of both clients and staff. The phrase "as far as is reasonably practicable" does not apply in civil matters. The penalties for a breach of civil law are usually just financial, but there is no limit to the level of damages that can be imposed.

Age of consent. The "Family law reform act 1969" states that those aged 16 and above can give consent to medical, surgical and dental procedures. Those under 16 can probably give consent if the practitioner judges them to have reached sufficient maturity to FULLY understand the implications of their request AND if they are given enough information for them to make a sound decision. A parent or guardian should be present at all times if under 16.

Offences against the person. Offences such as assault, actual bodily harm and grevious bodily harm as well as indecent assault need to be considered. It is legally possible to give consent to common assault, but not to any other. "

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Standard of premises

The guidelines are clear as to the standard of the premises that are used for skin piercing activities.

"Piercing studios must be physically divided into at least 2 areas: A front reception and waiting room with seating and displays and a treatment area seperated with full height walls and screened from the public area."

"The treatment area must be used solely for piercing and must be completely seperated from all other rooms (e.g. any room used for human habitation, hair salon, room used for tattooing etc.)"

"There should be an area of at least 5 square metres for each operative in the establishment to work in the treatment area. The treatment area must be adequately lit and ventilated."

"All internal walls, doors, windows, partitions, floors, floor coverings and ceilings must be kept clean and in such good repair as to enable them to be effectively cleaned."

"Work surfaces, floors and walls within the treatment area must be impervious, durable and washable. They must be clean and capable of being maintained in a clean condition."

"All furniture within the treatment area should be covered with a smooth, impervious surface to enable them to be effectively cleaned. Treatment beds and couches should be covered with a paper towel."

"There should be an adequate, constant supply of hot and cold water at a hand basin. The wash basin should be easilly accessible to the operator and be for his/her sole use for handwashing only. The taps should be of the mixer type with elbow, foot or infra-red operated taps. Liquid soap or detergent must be provided through a dispenser. Bars of soap must not be used. Disposable hand towels must be used for drying and NOT textile towels. A seperate sink not immediately adjacent to the treatment area should be provided for cleaning equipment. This sink should have a mixer type tap to ensure that water is at the correct temperature."

"There must be a tariff of charges prominently displayed which can easilly be seen by all persons entering the premises and a current registration certificate and certificate of attendance on a cross infection control course must also be on display."

"There should be no smoking, eating or drinking in the treatment area. No animals are allowed other than service animals used by those with disabilities."

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Personal hygiene

This is the section of the guidelines that I believe is the most important. What's the point of purchasing and using expensive equipment to clean and sterilize if the piercer is spreading germs around his or her studio ?

Handwashing

The guidelines state that:
"Handwashing is the single most important means of preventing spread of infection. Hands should be thoroughly washed using soap and hot water:

Hands should be thoroughly dried using a disposable paper towel. Finger nails should be kept short and clean. Cuts and abrasions to the hands and arms are to be covered with a waterproof dressing at all times. There should be no smoking, eating or drinking facilities in the piercing room."

Clothing

"Operators should wear clean, washable clothing. A clean garment should be worn at least daily and changed if it becomes soiled. Protective outer garments and/or a disposable plastic apron should be used when necessary and should be removed and stored in the treatment area before breaks, including lunch, smoking, drinks and toilet breaks."

Gloves

"Latex or synthetic rubber gloves must be worn by everybody coming into contact with bodies and secretions or fluids of others, or objects or equipment contaminated by them."

"The aim is to protect customers from germs the piercer may be carrying and to protect the piercer from any germs the customer may be carrying."

"A new pair of disposable gloves must be worn for each client and these should be replaced if a puncture is seen or suspected. Hands should always be washed, as the process of removal will result in the hands becoming contaminated."

(We actually believe that at least 3 pairs of gloves should be worn for each client and up to 8 pairs, depending on the procedure).

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Competency and training of practitioners

"All persons carrying out body art procedures must attend a relevant course on infection control and attend a refresher course at least every 5 years."

"They must also be constantly supervised during the first year of practice by a practitioner who has SUCCESSFULLY performed body art procedures routinely for the previous 5 years."

"It may take UP TO 2 YEARS full time practice to reach the MINIMUM level of competence."

"All persons must be able to demonstrate competency by answering questions put by the authorised officer or anyone they deem neccessary. They should be able to demonstrate knowledge and proficiency in subjects such as relevant anatomy, diseases and their transmission, infection control procedures, precautionary approaches to new procedures etc."

"Full records must be kept on the premises of all qualifications and courses attended and periods of supervision of all piercers. These details must be available for inspection at all times."

"Body art procedures must not be carried out by persons under 18 years of age."

"Training shall include procedures on dealing with body fluid spillage (blood, vomit, urine, faeces etc.), needlestick injury and all safe working methods established by the employer."

"A current registration certificate should be conspicuously displayed at all times. It must be clearly visible to all persons entering the premises. There must also be displayed a certificate of attendance at an appropriate infection control course."

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Anaesthetics

"The administering of local anaesthetic by injection, other than by a registered medical practitioner, is an offence under the 'Medicines act 1968".

"Administering of local anaesthetic creams, gels and sprays is not recommended. Piercers should not use prescription only topical creams such as EMLA."

"Ethyl chloride (freeze spray) SHOULD NOT BE USED UNDER ANY CIRCUMSTANCES as there is an appreciable risk due to flammability, cryogenic properties (frostbite) and respiratory sensitisation."

Although not part of the guidelines, the Cheshire and Merseyside Health Protection team, part of the health protection agency, has issued a notice to all attendees of the infection control awareness program to clarify the legal position regarding the supply and use of local anaesthetics.

"Each medicine is assigned one of three categories:

POM and P medicines can only be sold or supplied at registered pharmacy premises under the supervision of a pharmacist. POM's are sold or supplied in accordance with an appropriate practitioners prescription. It is a contravention of the medicines act for a supplier to sell or provide POM medicines to a business other than a pharmacy. It is also a contravention for someone to try to procure a POM from a pharmacy without a prescription.

EMLA local anaesthetic cream is a POM and therefore should not be supplied to a business other than a pharmacy or where a doctor or dentist can issue an appropriate prescription.

Ametop, another local anaesthetic cream is a P and although does not require a prescription if it is used other than on a personal basis it can only be used by a person knowlegable and competent in it's properties etc.

There are a range of exemptions which allow certain groups to sell, supply and administer particular medicines direct to patients, however body piercers do not fall within these exemptions."

This means that the procurement or supply of a POM such as EMLA would be contravening the medicines act and could lead to prosecution. In addition if a non prescription medicine is used there are issues around competency and knowledge to use and administer such a drug.

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Infection control procedures

"All persons carrying out body art procedures must attend a relevant course on infection control and attend a refresher course at least every 5 years. A certificate of attendance must be displayed in the premises."

Infection Hazards

"During any skin piercing procedure there is a risk of infection to both the operator and the client, as well as anybody else that may be exposed to body fluids and contaminated materials."

Local infections

"Infections may be locallised in the area of the piercing, perhaps due to staphylococcus or pseudomonas bacteria. They may give rise to locallised inflamation and pain, or result in more chronic problems with pus, exudate, odours and scar tissue."

"Viruses are of more concern, especially those which cause hepatitis B and C and HIV"

Hepatitis B

"Hepatitis B occurs by contamination with infected blood, serum or tissue fluids. Poor practice in tattooing and acupuncture have been known to cause outbreaks. The virus is very robust and able to survive for a number of years on laboratory work surfaces. In addition the virus is highly infective - one millilitre of blood may contain enough virus to infect up to 12,500 people. Body piercers should have a hepatitis B vaccination to protect themselves, their family and their clients.A tattooist in Bury, Greater Manchester infected 30 people with hepatitis over a 2 month period from one infected client"

"The sterilisation of equipment at 134 degrees C for 3 minutes destroys the hepatitis B virus."

Hepatitis C

"Hepatitis C is aqcuired through intraveinous drug use and the sharing of needles. There is a small risk of infection through skin piercing and infection through sexual intercourse can also occur. No vaccination is available for hepatitis C."

HIV and A.I.D.S.

"HIV is trnsmitted in the same way as Hepatitis B. Steps taken to eradicate the hepatitis B virus will also eradicate the risk posed by HIV."

Cleaning, disinfection and sterilization

"Clean is defined as - free from dirt or contaminating matter"

"Disinfection means the reduction in numbers of bacteria to levels that are unlikely to cause infection"

"Sterilisation is the process of rendering objects free from all forms of life including viruses, protozoa, fungi and bacteria and their

Effective infection control

"Equipment that comes in contact with intact skin must be cleaned before reuse. This includes chairs and workbenches. Equipment must be cleaned with detergent before it is sterilized. Equipment with complex shapes, such as forceps should be cleaned ultrasonically."

"All floors, work surfaces and equipment must be cleaned at least once a day using detergent. Surfaces must be dried using natural ventilation. Surfaces should be cleaned immediately soiling or spills occur or when visibly soiled. Walls and ceilings need only be cleaned periodically."

"Effective cleaning ensures that equipment is clean to the naked eye and free from any residues. Soiled equipment must not be stored or processed in clean areas."

"During skin piercing the skin, serum, blood and traces of tissue will contaminate the piercing equipment. It is therefore important that scrupulously sterile systems and equipment are maintained to prevent infection of piercing practitioners and their customers."

Sterilisation

"All equipment used to penetrate the skin must be sterile. Where reusable equipment has been in contact with broken skin, it should be considered contaminated and should, therefore, be cleaned and sterilised prior to reuse in accordance with manufacturers instructions. This means any equipment coming into contact with broken skin must be fit for sterilisation or must be disposed of as clinical waste."

"For most bodypiercing a hollow needle is used. This should be disposed of as a contaminated single use item."

Cleanliness

"Equipment must be clean to enable effective sterilisation."

Circulation

"There must be sufficient air/steam circulation round all of the equipment."

Moisture

"Steam is very effective in transferring heat to microorganisms and infective agents, ensuring their death or inactivation."

"The recommended method of sterilisation is autoclaving. This employs heat, the most efficient and reliable form of sterilization. These bench top autoclaves are either 'traditional' in which the steam passively displaces air from the autoclave chamber and load, or of vacuum design, which actively removes air from the chamber and load before the steam is introduced. The very best sterilisation practice requires the use of a vacuum steam sterilizer, to ensure that all parts of the load are exposed to the steam at the required temperature."

"Traditional bench top sterilisers are acceptable for solid or unwrapped instruments. The instruments must be placed in the chamber to enable drainage of all lumens or hollows. Pouches or other wrappings must not be used in a traditional bench top autoclave."

"For both types of equipment it is essential that the instruments are scrupulously, ultrasonically cleaned to remove visible contamination and debris before they are sterilised."

"The process of sterilisation involves exposing the equipment to heat for a specified period of time. This means that autoclaving at a higher temperature and pressure can be carried out for a shorter period of time.Traditional bench top sterilisers are acceptable for solid or unwrapped instruments. The instruments must be placed in the chamber to enable drainage of all lumens or hollows. Pouches or other wrappings must not be used in a traditional bench top autoclave."

At 121 degrees C a holding time of 15 minutes is required.
At 126 degrees C a holding time of 10 minutes is required.
At 134 degrees C a holding time of 3 minutes is required.

"Other 'sterilisation' methods include : Dry heat, boiling, pressure cookers, soaking in detergent, ultra-violet light exposure, dishwashers and microwave ovens. These methods may produce temperatures high enough to sterilise but they cannot be relied upon to satisfy all the requirements. NONE of these methods is recommended."

Skin disinfectants

Environmental cleaning and disinfection

"Successful cleaning depends on the selection of a disinfectant capable of performing the required task and its careful use under appropriate conditions of concentration, duration of exposure, temperature, pH and absence of neutralising substances."

"The effectiveness of chemical disinfectants is highly specific, for while some may be used on surfaces and equipment, others are only effective on skin."

"It is important to follow manufacturers instructions and that care is taken to ensure that chemicals are not stored in direct sunlight or in hot environments as thiese can dramatically alter the products efficiency. To maintain safe working methods it is advisable to restrict the number of chemical disinfectants as they may be hazardous if mixed together."

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Cross contamination

"Infection can be spread from client to client, client to operator, operator to client and even operator to operator, by the transference of bacteria or viruses through cross contamination."

"Cross contamination often arises from unforeseen causes such as handling telephones, verniers and rulers during a procedure or basic problems like ineffective cleaning, dirty door handles or confusing sterile and used instruments."

"Infection can occur where skin is pierced using the following faulty techniques :

It should be noted that in most skin piercing activities there is very little blood in evidence, however blood and serum need not be visible on a needle or instrument to pose an infection hazard."

"Unbroken human skin without cuts or lesions is the body's foremost natural defence against infection from the environment."

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Appropriate jewellery

"Piercers are advised to use the following metals :

Silver is not suitable for use with new or unhealed piercings due its property of tarnishing easilly. It causes discoloration of the piercing and allows microorganisms to become entrapped."

Allergic response to jewellery

"It is recognised that jewellery containing nickel may cause allergic reactions in some people. This can prevent proper healing and cause sensitivity to other items. Sensitised individuals find many belt buckles, wristwatches, spectacle frames and jewellery impossible to wear.

The issue of nickel allergy has been addressed in Directive 94/27/EC which states that nickel may not be used :

These requirements came into force on 20th July 2000.

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Use these links to find your way around this page
The law regarding body art procedures

Standard of premises

Operators personal hygiene

Competency and training

Anaesthetics

Infection control procedures

Cross contamination

Appropriate jewellery

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