Dear E. Angel,

I have a client who wants to get two ear cartilage piercings (tragus and helix) but she has an illness called Ehlers Danlos that might affect healing. I am not sure if it would be a good idea to pierce her. Do you have any information or know where else I could find out?

Also, what other diseases should I be on the lookout for to avoid problems? I want all of the piercings I do to heal great, but I don’t want to turn people away when it is safe to pierce.

Thank you, T.

Dear T.,

Certain medical conditions do make piercings riskier, and in some cases inadvisable. Ehlers-Danlos Syndrome (EDS) is a spectrum of chronic genetic disorders of the connective tissue, caused by a defect in collagen production. It affects approximately one in five thousand people(i). Depending on the particular mutation, severity of the illness can range from mild to life threatening. Common aspects of EDS that would concern piercers are overly elastic, severely fragile skin that bruises and scars easily—and delayed wound healing(ii). EDS also causes hyper-flexible joints, among a plethora of other symptoms. There are a number of sub-types and variants of the disorder(iii), but tissue fragility is the unifying feature among them all.

Collagen is a protein that is the primary structural material for all of our connective tissues including skin and cartilage. It provides strength, body, and elasticity. Collagen makes up about 80% of the dermis(iv)—the skin we pierce and place jewelry through. Therefore, a collagen dysfunction naturally impacts wound healing.

In response to your question, I embarked on my own informal research and found a number of forums in which EDS sufferers discussed piercings. Out of more than forty piercees who commented, only two did not experience healing problems of some type. Though they both remarked about unexpected and undesired stretching of their healed piercings due to tissue fragility.

From my unofficial survey, in conjunction with a review of the medical literature, a few things became clear about how EDS impacts piercings:

1. They heal much, much more slowly than normal—if at all. Several had worn piercings for over a decade (or two) without healing completely!
2. Even with old, fully healed piercings, flare-ups including pain, redness, and weeping are common.
3. There is a greater incidence of piercing infections than in the general population, including frequent abscesses.
4. There is a higher chance of abnormal scarring including atrophic (pitting), hypertrophic (enlarged), and keloid (greatly oversized) scar formation. Though that last term is commonly applied incorrectly to less extreme scars, posted photos did document actual keloids.
5. Unplanned and undesired (usually permanent) stretching is common, as is migration and tearing.
6. Cartilage piercings were virtually always described as especially problematic and difficult to heal.

 

One woman, who had purposely stretched her ears, consulted a surgeon about having them closed. The doctor recommended against it because of the risk of heavy scarring that could result, and issues that EDS patients have with the local anesthetics that are required for such procedures.

It seems that most patients know the diagnosis of their specific variant, as the symptoms and effects are quite different from one type to the next. Those with the hypermobile EDS (hEDS) variation don’t seem to suffer from severe skin healing complications like the other forms do. In my investigation, both of the piercees who experienced only stretching problems had this variant. So, a client with hEDS might be a better candidate. If someone shares their classification with you, then it should be taken into consideration. Based on my research, if hEDS is not the person’s diagnosis or if the specifics are unknown, I would definitely decline to pierce—especially cartilage.

Note that another variant, CardioVascular (cvEDS), could be of exceptional concern for piercing safety because these individuals have mitral valve prolapse (MVP) or other serious heart conditions. Patients with MVP or certain cardiac disorders including rheumatic heart disease, and those with a valve replacement or prosthetic material from cardiac repair, are susceptible to infective endocarditis (IE). This is a potentially deadly infection of the lining of the heart or its valves. If bacteria enter the bloodstream at the piercing site, they can travel through the circulatory system and cause this type of infection in damaged and weakened hearts. A “steep rise of IE cases directly attributable to piercing” was reported in the medical literature(v).

A prospective piercee with such a medical history (or any ailment of serious concern) should be required to submit proof that they have consulted with their doctor before proceeding—if you are open to piercing them at all. Politely declining is always a valid choice if you’re not comfortable or feel the risks are too great.

Anyone who must ordinarily take antibiotic prophylaxis (preventive treatment) prior to dental or “invasive” procedures, should consult their physician about whether a prescription is recommended before piercing. The current guidelines suggest preventive antibiotics less often than in the past. Most experts no longer advise prophylaxis for dental procedures in patients with prosthetic joints, according to the updated 2017 recommendations(vi). Though a recent client who’d had a hip replacement was prescribed antibiotics before his appointment for a pair of frenum piercings, so checking is still appropriate.

I was somewhat familiar with Ehlers-Danlos because I had pierced someone who later informed me that he’d been diagnosed with it. I did a “snug” (ear cartilage) piercing on him, back before it was given that name…and it didn’t heal. But I did not know all of the above before responding to your question, so I did some research. You can learn to perform your own comprehensive and reliable inquiries in order to determine the best course of action when something else comes up in the future.

There is a lot of misinformation to be found on the Internet; so, how can you tell what’s valid and accurate? I seek out trustworthy sources for quality data and facts, rather than posts on social media, commercial websites (selling anything), and personal sites. I never use Wikipedia, which is not considered a reliable resource due to its user-generated, openly editable content. I look for scientific research studies vii, viii, ix and seek out major organizations such as (in this case) Ehlers-Danlos Society, American Heart Association, and National Institutes for Health. I also check academic texts on university websites. This was the first time I have used forums as a reference. Though only anecdotal, the comments confirm what I learned from the scientific literature, so I opted to incorporate them.

There are many medical issues that can raise risks of infection, delayed healing, and other complications. Immune system disorders obviously fall into this category including Lupus, Rheumatoid Arthritis, and HIV/AIDS. Diabetes can be a major issue and it is incredibly common; I wrote an article about it several years ago. There’s no way I can delve into it all now, but perhaps a piece answering this more thoroughly will appear in a future issue of Pain Magazine?

Any time you’re concerned about a medical condition, it is reasonable to require that the client bring a signed doctor’s note before you agree to pierce. Acquire skills to educate yourself conscientiously so that you can exercise good judgment based on solid information.

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(i) https://www.ehlers-danlos.com/2017-eds-classification-non-experts/hypermobile-ehlers-danlos-syndrome-clinical-description-natural-history/heds
(ii) https://www.ehlers-danlos.com/wp-content/uploads/eds-anesthetic_management.pdf
(iii) https://www.ehlers-danlos.com/eds-types/
(iv) https://www.derm101.com/inflammatory/embryologic-histologic-and-anatomic-aspects/collagen/
(v) https://academic.oup.com/jac/article/53/2/123/850488
(vi) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5323496/
(vii) https://www.omicsonline.org/open-access-journals-list.php
(viii) https://www.nih.gov
(ix) https://www.researchgate.net/