EDS & HSD Through the Dermatologist's Lens

Welcome back to the Bendy Bulletin! One of the things I love most about writing this newsletter is introducing you to clinicians who understand hypermobility from multiple perspectives - not just through textbooks, but through caring for patients every day.

Today’s guest is someone many of you may already recognize.

Dr. Sonal Choudhary is a dermatologist, dermatopathologist, and director of the UPMC Integrative Clinic. She specializes in connective tissue disorders, inflammatory skin disease, and complex multisystem conditions. She also lives with hypermobile Ehlers-Danlos syndrome (hEDS), giving her a unique perspective as both physician and patient.

When most people think about EDS or HSD, they immediately think about joints.

But the skin is connective tissue, too.

In fact, many of the earliest clues to hypermobility show up in the skin long before someone receives a diagnosis. Recognizing those patterns can help patients receive more thoughtful care - and help clinicians connect dots that might otherwise be missed.

I’m excited to share Dr. Choudhary’s practical guide to recognizing, treating, and supporting the dermatologic manifestations of EDS and HSD.

When evaluating someone with suspected EDS or HSD, the skin often provides valuable diagnostic clues.

Many patients have spent years being told their skin is simply “sensitive” or that they’re “just prone to bruising.”

In reality, these findings may all be part of a connective tissue disorder.

Some of the most common findings include:

• Soft, velvety skin

• Mild to significant skin hyperextensibility (stretchiness)

• Skin that recoils more slowly than expected

• Thin or translucent skin (more commonly seen in classical or vascular EDS)

One thing I hear often from patients is:

“I’ve always known my skin was different.”

That observation is worth paying attention to.

Healing can look different in people with connective tissue disorders.

You may notice:

• Thin, “cigarette paper” scars

• Widened surgical scars

• Delayed wound healing

• Easy bruising after even minor injuries

These findings tend to be more pronounced in classical EDS but can also occur - more subtly - in people with hEDS and HSD.

Many patients report bruises appearing without remembering any injury at all.

Dermatologists may also see:

• Spontaneous bruising

• Larger-than-expected hematomas after procedures

• Small visible blood vessels (telangiectasias) in certain subtypes

While easy bruising is common in connective tissue disorders, it should not automatically be attributed to EDS or HSD. Other causes - including platelet or clotting disorders and medications or supplements that increase bleeding risk (such as fish oil, ginkgo, garlic, or ginseng) - should also be considered when clinically appropriate.

Patients frequently experience additional dermatologic conditions, including:

• Atopic dermatitis (eczema)

• Chronic spontaneous urticaria (hives)

• Mast cell activation–type symptoms

• Acne caused by braces, taping, or friction

• Piezogenic papules

• Stretch marks that seem disproportionate to weight changes

Researchers continue to study the relationship between mast cell dysfunction and hypermobility. While we still have much to learn, many patients report symptoms that deserve thoughtful evaluation rather than dismissal.

People with EDS and HSD often:

• React to adhesives or sutures

• Scar more dramatically after procedures

• Experience chronic itching

• Flush because of dysautonomia

• Report “sensitive skin” with many products

Because these patients often see numerous specialists, dermatologists have an opportunity to do something incredibly meaningful:

Validate what they’re experiencing.

Sometimes simply recognizing the pattern is the first step toward helping someone feel seen.

A healthy skin barrier can reduce irritation and improve comfort.

Helpful strategies include:

• Thick ceramide-rich moisturizers

• Ointment-based products for cracked or fissured skin

• Gentle cleansers

• Avoiding over-exfoliation

• Short, lukewarm showers instead of long hot ones

Small adjustments during procedures can make a meaningful difference.

Consider:

• Using smaller-gauge needles when appropriate

• Reducing tension on wound closures

• Layered closure for selected excisions

• Leaving sutures in slightly longer when clinically appropriate

• Starting silicone gel sheets early during scar healing

• Counseling patients beforehand about the possibility of widened scars

Setting expectations ahead of time helps patients make informed decisions and reduces unnecessary anxiety afterward.

Because adhesive sensitivity is so common, alternatives may be better tolerated.

These include:

• Silicone-based dressings

• Hypoallergenic paper tape

• Non-adhesive wraps when possible

When removing adhesive products, taking them off slowly - and using oil when appropriate - can help minimize skin injury.

Itching in EDS and HSD isn’t always caused by the same thing.

Depending on the individual, it may be related to:

• Skin barrier dysfunction

• Neuropathic pain pathways

• Mast cell activation–type symptoms

• Dysautonomia

Management may include:

• Antihistamines when hives are involved

• Topical pramoxine

• Cooling or menthol-containing products

• Neuropathic medications in selected patients

• Nervous system regulation strategies, including breathwork and vagal nerve support

As always, treatment should be individualized based on the underlying cause.

Many patients with hEDS or HSD struggle to tolerate standard acne treatments.

Instead of aggressively drying the skin, consider:

• Lower-strength retinoids

• Barrier-supportive skincare alongside active ingredients

• Patch testing when reactions are frequent or unexplained

Listening when patients say, “Everything burns my skin,” can help guide a more successful treatment plan.

No vitamin or supplement can correct the underlying collagen differences seen in EDS.

However, optimizing overall health remains worthwhile.

This may include:

• Adequate vitamin C intake

• Sufficient daily protein

• Optimizing vitamin D when indicated

• Addressing gastrointestinal dysfunction that limits nutrient absorption

• Encouraging appropriately supervised resistance training within safe joint limits

The goal isn’t to “fix” connective tissue - it’s to support the body’s overall function.

Dermatologists should consider involving other specialists when appropriate, including:

• Genetics (especially if classical or vascular EDS is suspected)

• Rheumatology

• Cardiology (particularly when POTS is suspected)

• Pelvic floor physical therapy

• Pain medicine

• Neurology

Some findings warrant urgent genetic evaluation for vascular EDS, including:

• A family history of arterial or organ rupture

• Severe bruising after minimal trauma

• Personal history of organ rupture

• Thin, translucent skin with prominently visible veins

Recognizing these features can be lifesaving.

If you notice several of the following together:

• Soft, hyperextensible skin

• Unusual scarring

• Joint hypermobility

• Chronic itching alongside dysautonomia symptoms

…it may be worth considering hEDS or HSD in your differential diagnosis.

Sometimes the skin is the clue that helps the rest of the picture come into focus.

The skin is often one of the first places connective tissue disorders reveal themselves.

By recognizing these patterns, making thoughtful procedural modifications, and validating patients’ lived experiences, dermatologists can play an important role in earlier recognition and more compassionate care.

I’d love to hear from you.

Have your skin symptoms ever helped lead to your diagnosis - or were they dismissed for years?

Share your experience in the comments. Your story may help someone else recognize that what they’ve been experiencing isn’t “just sensitive skin” after all.

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The information provided here is for educational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. No physician-patient relationship is established by reviewing this material. Always consult your own healthcare provider or medical team before making any decisions about medications, supplements, or treatments. Dr. Bluestein is a licensed medical professional, but she is not your personal physician in this context and cannot provide individualized medical care, prescribe medications, order tests, or make referrals outside of a formal clinical relationship.

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