Note: The companion piece for this essay is “Tattoos When You Have hEDS, MCAS, &/or POTS? (It’s Complicated)“ and in it, I address the topic of tattoos and complex illness from the client’s perspective.
If you are starting with this essay, you probably are a tattoo artist. There is a lot of useful information for you in the above-referenced post, including consideration of how an increasing prevalence of complex illness might affect your profession. This one, for its part, is more to-the-point and less a narrative. There is an incredible amount of information pertinent to this topic so I remain as brief–yet thorough–as can be. Definitely follow to the endnotes to expand upon what you are discovering in the main text.
Most important of all: I thank you, in advance, for caring enough about your profession to read these essays. Thank you for taking the time to learn about these clients, the ones who might present some extra challenges for you.
Note: this essay is for information purposes only. Whether or not the artist decides to tattoo a person with any health conditions is an individual shop or artist choice.
Ehlers Danlos Syndrome:
Ehlers Danlos syndrome is a disorder of the connective tissue.
This is a heritable connective tissue disorder (HCTD) that affects collagen and is characterized by soft skin, loose joints, chronic pain, easy bruising, and abnormal scarring. Hypermobile EDS (hEDS), and hypermobility spectrum disorder (HSD), are much more common than many people recognize.
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My guess is that more tattoo artists have inked people with EDS than they realize. Several of my patients are covered with tattoos and they got them before they knew that they had EDS. Even a quick review of online support group discussion of tattoos and EDS demonstrates that my patients are not unusual in this regard.
Medical students are taught to look for what is common (“when you hear hoofbeats, don’t expect a zebra”) and people with EDS are the zebra. It has become the mascot of the EDS community, so if you hear anyone referred to as a zebra, that’s a person with EDS.
Health concerns associated with EDS and tattoos:
- Poor or delayed healing;
- Easy bruising;
- Danger of blowouts;
- The tissue might not retain the ink; &/or
- Associated conditions (MCAS, POTS) may heighten the risk of adverse events.
The tattoo artist needs to be aware of these issues but EDS is a complicated condition and Western biomedical doctors do not always know what to do about it. It’s not up to a tattoo artist to respond with the knowledge of a licensed medical care provider who is a specialist in HCTDs.
What tattoo artists should know:
1). It is your client’s responsibility to prepare and to have a plan:
If your client identifies as being a person with EDS, they should be able to articulate how they intend to prepare for the tattoo and what their concerns may be. But…has the client spoken to their MD? Have they read “Tattoos When You Have hEDS, MCAS, &/or POTS? (It’s Complicated)“? If the client hasn’t planned ahead, that tells you something.
2). You are not the one to be diagnosing anyone:
Getting diagnosed is a grueling process that usually takes around a decade of suffering and gaslighting and the average primary care physician doesn’t diagnose. It’s a task for specialists (usually a rheumatologist, but geneticists will diagnose in some instances).
3). There are some tangible skin signs that tattoo artists should be able to identify and take into account:
- Cigarette paper scars are a signal that the tissue might have healing issues, and these are common with EDS.
- Long stretch marks that look like zebra stripes on a person’s rib cage are another indication that the client’s connective tissue might be fragile.1
- Livedo reticularis, or mottled skin, is not unusual for people with EDS. (As an acupuncturist, I don’t needle people over areas that are mottled and, as you will see in the linked article in the footnote, tattooists are cautioned to avoid inking over this type of skin.)2
4). If your client does identify as a person with EDS then be aware that sitting in certain positions might cause a subluxation or, at best, extreme discomfort:
Dislocation is what it sounds like: the bones of a joint separate completely. A subluxation is when the bones of a joint slip apart but do not entirely detach. It’s a thing, so definitely negotiate a comfortable sitting position if the tattoo is going to take a long time.
5). EDS and HSD can directly affect the way the tissue accepts and retains ink but it’s important to be aware of the common comorbidities. These can really wreak havoc if not addressed.
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And this brings me to mast cell activation syndrome (MCAS):
MCAS is a condition where the immune cells (the mast cells) overreact to stimuli and cause repeated anaphylactic response.
This could be anything: smells, foods, artificial dyes, chemicals… basically, anything. There can be no known trigger but the mast cells degranulate as though they were under attack from a thousand different allergens.
MCAS used to be relatively rare, but COVID, among other shifts in public health, changed that. It’s not unusual for a person with EDS to have MCAS (and POTS, but we’ll get to that).3
Please be sure to carefully read the section of MCAS in the companion piece to this essay (“Tattoos When You Have hEDS, MCAS, &/or POTS? (It’s Complicated)“) for more information on MCAS and tattoos.
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The nickname for people with MCAS is “mastie.”
Health concerns associated with MCAS and tattoos:
- Extreme reaction to the tattooing process, including anaphylaxis;
- Rashes and inflammation in the tattoo that do not abate;
- Swollen tattoos that may or may not go back to normal; &/or
- Itchy or inflamed tattoo that may or may not heal.
I have had a number of patients with MCAS who have tattoos. From what I have seen, the tattoos swell up and itch when the patient is in a flare. I personally, as a mastie, would not get a tattoo because I am a sensitive flower. I don’t think I’d have a ghastly reaction to a tattoo but I’m not sure that I wouldn’t and that is enough for me.
I would hope that most potential clients would know their limits and avoid getting a tattoo if they have MCAS to an extreme degree but people are funny like that. They don’t always make the best decisions. And sometimes, the person’s tattoos are a lifeline and the individual decides it’s worth the risk (and the tattoo artist should have the chance to agree or disagree with this decision, of course…).4
What tattoo artists need to know:
1). As with EDS, this is a complex condition that is challenging to diagnose and doing so is not in a tattoo artist’s wheelhouse by any means.
2). COVID and post-COVID syndromes are causing rates of MCAS to increase. It may not be something you see much of now, but in combination with increasing rates of autoimmune disease and metabolic disorder, clients who may not be a candidate for tattooing could show up in your shops anyway. Do you have a plan for this?
3). If you decide to tattoo, at least consider your inks and any topicals for surface numbing (I go into this in greater detail in the companion essay).
4). People with EDS and MCAS will often have a third condition and, in so doing, they live with what is referred to as “the trifecta.” This is when a person has EDS, MCAS, and POTS.
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This brings us to a third condition of note, postural orthopedic tachycardia syndrome, or POTS:
Postural orthopedic tachycardia syndrome is when the person’s heart beats much faster than it should when they go from sitting to standing.
It’s a nervous system disorder that can be the main issue (the tachycardia) or it can be part of a more complex dysautonomia presentation (when the autonomic nervous system does not function correctly on multiple levels).5
As with the first two issues, it is not easy for patients to get a diagnosis. A tattoo artist should not feel responsible for noticing possible symptoms and deciding whether or not someone has POTS.
Yes, people with POTS might refer to themselves as potsies.
Health concerns related to POTS and tattoos:
- Dehydration;
- Fainting; &/or
- Exacerbation of symptoms of adjacent conditions (EDS, MCAS).
What tattoo artists need to know:
1). In many ways, you already know this part. You’ve dealt with fainters. You have policies and instructions to help people to not pass out during the process.
2). One feature of POTS is blood pooling in the lower extremities. This may affect where you deem it safe (or not) to tattoo.6
3). My experience thus far has been that people with POTS, diagnosed or not, are pretty responsible about knowing how much salt they need, what they need to do to remain hydrated, and so forth. If this is a first tattoo, they might not realize just how much extra they may or may not need. Are they going to plan ahead and bring supplies? Ask about that and make sure that they have a plan.
4). Does the person also have EDS and MCAS? That can change the dynamic but, with planning and good communication, there may be options.
Which brings me to my conclusion:
As I discussed in the companion piece to this one…the world is a changed place. Rates of autoimmune disease, connective tissue disorder, POTS, MCAS, allergies…all of these things are becoming more and more prevalent. Tattoo artists do not need to become medical doctors but they do need to be aware.
Part of the reason I wrote my book is because, after writing two blog posts on the topic, I was getting emails from Europe, Canada, and from one side to the other of the United States from people asking for more information. I couldn’t keep up with it and the requests finally inspired me to write what became Chinese Medicine and the Management of Hypermobile Ehlers Danlos Syndrome. It’s not the case for all my patients, but many of them live with complex, chronic, or mystery illnesses (that’s when the person’s life is an utter misery but their labs always come back “normal” and their MD tells them that it’s in their head or worse…that they could lose weight and then would no longer feel sick).
Complex, chronic, and/or mystery conditions are here to stay. And now, we are all, medical care providers and people who seek medical care alike, navigating a new and uncertain terrain.
Clients who come to see you can have a much better experience when they take responsibility for their end of things, and they need to communicate with you, the tattoo artist. You, the tattoo artist, of course will need to remain aware and up-to-date regarding this shifting landscape of public wellbeing. Communication, awareness, and integrity will take us all far.
Thank you for reading this essay, and may it provoke thought and greater knowledge among the good people of your profession.
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Dr. Paula Bruno, Ph.D., L.Ac., is a licensed acupuncturist and herbalist, an AOBTA-CP traditional Chinese bodywork therapist, an author, and a health coach. She maintains an active and growing practice at Two Hearts Wellness, her Austin, TX office. Dr. Bruno is also available for distance appointments for wellness consultation or coaching.
In her first career, she was a Spanish professor.
Dr. Bruno’s specialties as a Chinese medicine practitioner include: • Musculoskeletal health (acute or chronic pain relief; Ehlers Danlos syndrome & hypermobility support) • Digestive support, gut health, and weight loss • Aesthetic treatment, including scar revision • Men’s health • General preventative care and wellness support for all persons.
She is the author of Chinese Medicine and the Management of Hypermobile Ehlers Danlos Syndrome: A Practitioner’s Guide.
When you are ready to discover what traditional medicine plus a vibrant and engaged approach to holistic health can do for you, either contact Dr. Bruno or book an appointment online.
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Two Hearts Wellness/Holistic Health & hEDS does not accept paid advertising on this website
Note: Material on this web site site is not intended to diagnose, prevent, treat, or cure any disease, illness, or ailment. A Chinese medicine practitioner in Texas identifies syndrome patterns but does not diagnose illness. Material on this web site does not purport to identify syndrome patterns.
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- “Rheumatology for Patients” for useful pictures of cigarette paper scars and the type of stretch marks you might see on a person’s back if they have an HCTD. You also might see this on patients with Marfan syndrome, which is also an HCTD. If you are interested in learning about EDS, I highly recommend my book, Chinese Medicine and the Management of Hypermobile Ehlers Danlos Syndrome. Chapter one outlines EDS and all the common comorbidities in a way that non-professionals can easily understand. ↩︎
- Livedo reticularis (which I discuss in my book) is fairly common, as are other types of mottling. Whenever the client has remarkable flushing or blanching of the skin, this can be a marker for a number of complicated issues. In the context of a tattoo, this might be a signal for you to be extra attentive to dizziness or potential for fainting. For further commentary, please refer to “Tattoos and vascular anomalies.” ↩︎
- There are thirteen official subsets of EDS and hEDS is the only one without a clear genetic marker. Refer to “What Causes Hypermobile Ehlers Danlos Syndrome? (A Summary of Theories)” for the six current theories pertaining to hEDS, one of which is that it is strongly related to MCAS. ↩︎
- This Reddit conversation, “Anyone have tattoos?” is an eye-opener. It’s a tough call, because tattoos are genuinely meaningful to people for so many reasons. For some in the community, tattoos hold an incredible signficance that they wouldn’t for a normie. “Inking Against Invisibility” is a long read but it may shed light on why a person with EDS would so dearly love her tattoos. “32 Gorgeous Tattoos Inspired by Ehlers-Danlos Syndrome” demonstrates that yes, zebras can get tattooed. “30 Gorgeous Spoonie Tattoos” shows that potsies can get tattoos. FWIW, one of the tattoo artists on Ink Master has EDS and quite a few tattoos (“Ink Master Caroline Evans: Living with EDS“). Long story short? None of these conditions are quite as rare as they’re posited to be, and education and awareness is key to providing (and experiencing, if you’re the client) a beautiful tattoo that will heal in an optimal fashion. ↩︎
- Dysautonomia is … a lot. It can be fairly (or extremely) disabling. Yes, people with EDS and MCAS, if not the full trifecta, can and do suffer from dysautonomia. Both dysautonomia and POTS are a potential after-effect of COVID and they are becoming much more common ailments as a result. And though it’s challenging to visualize someone with dysautonomia going to a tattoo shop and signing up for some ink, you never know. If you’d like to read more about dysautonomia, see “What is dysautonomia, and what are some of the different types?” It is definitely complicated. ↩︎
- Refer also to note 2, above, but for more information on blood pooling and POTS, see “Postural Orthostatic Tachycardia Syndrome (POTS).” ↩︎
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