Skin signs are a very important clue as to the possible presence of hypermobility syndromes. There may be skin hyperlaxity, easy bruising, abnormal scarring (often described as ‘atrophic’, ‘papyraceous’ or ‘keloid’ scarring), and the onset of stretch marks at an early age at multiple sites.
These features arise because the structural proteins produced, such as collagen, fibrillin and fibronectin, are not as tightly or evenly knit together when compared to other peoples’ skin. The way these structural proteins are made and interact with each other is genetically determined. There is nothing that can be done to stop it happening by for example injections of collagen or other such medical intervention. General skin care is important, e.g., trying to avoid trauma and allowing time for wounds to heal.
This is characteristic for all the Ehlers Danlos (EDS) subtypes, except for the Vascular type. It is most prominent in the Classic type of EDS, but may be present to a lesser extent in the Hypermobility type and Joint Hypermobility Syndrome (JHS). In the Vascular EDS, the skin is thin and transparent.
Hyperextensibility is measured by stretching a fold of skin over the back of the hand by pinching the skin between thumb and second finger and pulling the skin fold until resistance is felt. Doctors who see a lot of hypermobile and normal people will develop a skill for sensing whether the skin is more extensible than normal. On letting go of the stretch the skin should quickly return to its usual shape. In a rare group of conditions called cutis laxa syndromes, the skin is redundant and hangs in loose folds, returning very slowly to its former position after being stretched.
These are common in pregnancy, obesity, longterm use of corticosteroids, or in the endocrine disorder called Cushing Syndrome where the body produces too much steroid. The typical sites under these circumstances where stretch marks might be seen are the abdomen and lower back. In the hypermobility syndromes stretch marks may appear from an early age and at atypical sites such as the elbows, chest, under the arms, and on the inner thigh. This is common and seen to varying degrees of severity in JHS and EDS, and to a lesser extent in Marfan syndrome.
Easy Bruising and Bleeding
Easy bruising is also common in the hypermobility syndromes, especially in EDS. There may also be a tendency toward prolonged bleeding, e.g. following brushing of the teeth. A doctor may test the blood for a coagulation (clotting) abnormality or a platelet abnormality (platelets help the blood to clot), and find nothing wrong. This is because either the bruising is occurring because the skin is fragile and the small capillary blood vessels are breaking, or there is a subtle problem with the platelets that needs a more detailed assessment by a Haematologist (Blood expert). If there is something wrong with the coagulation tests then this is not due to the EDS / JHS and needs further investigation.
Slow/Poor Wound Healing
The most common causes for poor healing are natural ageing and corticosteroid excess. However slow or poor healing is a feature from an early age in the hypermobility syndromes. There are other less common conditions that lead to skin fragility and scarring and these should always be consider (e.g., the porphyrias (porphyria cutanea tarda), the mechano-bullous diseases (epidermolysis bullosa simplex) and vitamin C deficiency).
Delayed wound healing and atrophic scarring may be prominent in EDS, especially in the Classic type, and rarer subtypes such as the Kyphoscoliotic and Arthrochalasia type. However, even in the common conditions of JHS / EDS- Hypermobility type healing may be abnormal. This often only comes to light after surgery when the scar becomes thin and stretched. One should always be cautious about the risks of poor wound healing. This should always be considered when surgery of any kind is being considered.
Dr Alan Hakim MA FRCP
Consultant Rheumatologist and Physician, Barts Health NHS Trust, London
Written June 2013, Adapted from Hakim & Sahota 2006. Planned Date of Review 2016
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