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Anyone who goes into a tattoo parlor in North Carolina can be assured that it has a permit from the state health department and that inspectors have checked the premises for safe and sanitary conditions. But go for a body piercing in the state and there’s no such protection. A state law, approved in the 1990s, regulates tattoos but doesn’t apply to other forms of body art.

“Most people think it’s all regulated,” said state Rep. Kevin Corbin, a Republican. “But we found out there’s no law on the books.”

North Carolina is not alone. State legislators and health officials across the country are trying to keep up with the growing popularity and evolving trends of body art.

Health officials worry that unregulated body art studios may not follow safe practices, which can lead to scarring, nerve damage and infections, including hepatitis C, the leading cause of liver cancer in the United States.

“The body art industry is much more nimble than the government,” said Doug Farquhar, who tracks the issue in his role as the director of environmental health for the National Conference of State Legislatures.

Nearly 4 in 10 people born after 1980 have a tattoo and 1 in 4 has a piercing someplace other than an earlobe, the Pew Research Center has reported. (The Pew Charitable Trusts funds both the center and Stateline.)

Nearly every state regulates body art, but laws vary widely. Most states do agree on one thing: age limits. At least 45 states (including Maryland, Virginia and the District) prohibit minors from getting tattoos, and 38 states prohibit body piercing and tattooing minors without parental permission, according to NCSL.

Oregon extensively rewrote its tattooing regulations in 2012, updated them last year and in January clarified that “microblading,” in which a practitioner uses fine needles and pigment to create eyebrow hairs, is tattooing and not an aesthetic, or cosmetic, practice.

Oregon requires practitioners to have hundreds of hours of training and pass written exams before being licensed for specific types of body art. Georgia is among states that do not regulate the industry, but most Georgia counties have adopted ordinances regulating body art.

Maryland does not license body artists, though it requires them to use sterile instruments, wash their hands, wear disposable gloves during procedures and cleanse customers’ skin. They also must maintain three years of customer records and make them available to health officers if requested. But some Maryland localities require licenses.

Virginia issues licenses for tattoo artists and requires an examination. The District has regulations, but according to at least one report, they are loosely enforced.

North Carolina is one of at least six states considering body art legislation this year. Corbin co-sponsored a bill updating the tattoo law to include other types of body art. It passed the state House in April and is under consideration in the Senate.

The sharp increase in hepatitis C cases in the past few years has intensified states’ concern about sterile and sanitized needles and equipment and about associated health and safety training.

New hepatitis C infections in the United States tripled between 2010 and 2015, to more than 2,400, the Centers for Disease Control and Prevention reported last month. The CDC blames the increase on the rise of injection drug use associated with the opioid epidemic and says major studies have not shown hepatitis C to be spread through licensed tattooing facilities.

“However,” the CDC said, “transmission of hepatitis C (and other infectious diseases) is possible when poor infection-control practices are used during tattooing or piercing.”

An old concern

Health officials have worried about the health risks of tattooing for decades. New York City banned tattooing in 1961, citing concerns about hepatitis. Tattooing continued underground, however, and the ban was lifted in 1997.

In 2015, New York Gov. Andrew M. Cuomo (D) signed a law requiring tattoo artists to use single-use needles and supplies of ink. The body art community protested that the law’s language was overly broad, and Cuomo rescinded the measure. The state health department is developing new rules.

The American Red Cross requires someone who has had a tattoo to wait a year before donating blood if the tattoo was applied in Georgia, Idaho, Maryland, Massachusetts, Nevada, New Hampshire, New York, Pennsylvania, Utah, Wyoming or the District — jurisdictions that do not regulate tattoo facilities. No waiting period is required if the tattoo was applied in a state that requires tattoo shops to use sterile needles and single-use ink.

Tattoo ink, which is not regulated or tested by the federal government, is a potential health risk, but no outbreaks of infection from contaminated ink have occurred since 2012, the Food and Drug Administration reports.

Craving regulation

State legislators, recognizing that they aren’t experts in body art’s best practices, often call on practitioners to help write and enforce laws.

San Francisco body piercer Steve Joyner of the Association of Professional Piercers has helped about two dozen states write legislation over the past two decades.

“The downfall of politicians is that they really don’t understand our industry,” he said, adding that many state legislators have never set foot in a tattoo or piercing studio.

One of the first instances of body art practitioners asking to be regulated was in Florida, where a piercing law was enacted in 1999 with input from the industry. Tattooists soon started lobbying for state regulations, too.

“The tattoo industry wanted to ‘pedigree’ their profession. That’s the word they used,” said Gina Vallone-Hood, environmental administrator for the Florida Department of Health’s Bureau of Environmental Health.

The Florida legislature passed a tattoo law in 2010, and the Department of Health started licensing tattoo artists in 2012. Now, 450 piercing shops and 6,000 tattooists are licensed in Florida.

Michael Crea, a piercer for 20 years who owns a shop in Sarasota, is president of the Florida Environmental Health Association. He also runs the certification class that is required of piercers.

“You really don’t want people working out of their house,” he said. “We do deal with blood and body fluids. We break the skin. You can be spreading hepatitis, MRSA [methicillin-resistant Staphylococcus aureus] or AIDS, and you don’t want that.”

But Crea and other practitioners say that even when regulations are on the books, enforcement can be weak. Health inspectors often are responsible for checking out a wide range of potential hazards — from septic tanks to swimming pools — and can’t be expert in everything.

That’s why the National Environmental Health Association will feature a live tattooing demonstration at its annual conference in July in Grand Rapids, Mich.

“It will be a safe space for health inspectors to ask questions,” said Christl Tate of the association. “Our mutual goal is protecting the public health.”

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