BACKGROUND

Flawless skin is one of the most universally desired features, and demand for improvements in skin quality is growing rapidly. Skin quality has been shown to substantially impact emotional health, quality of life, self-perception, and interactions with others. Although skin quality improvements are a common end point in studies of cosmeceuticals, they are rarely assessed in clinical studies of other aesthetic treatments and products. Descriptive terminology for skin quality parameters also varies considerably within the aesthetic field, relying on a range of redundant and occasionally contradictory descriptors. In short, skin quality has not been clearly defined.

OBJECTIVE

The goal of this review is to highlight the importance of skin quality to patients and physicians, explore known and unknown factors comprising skin quality, and provide clarity regarding terminology, descriptors, and evaluation tools for assessing skin quality.

MATERIALS AND METHODS

A review of the literature on skin quality was performed without limitation on publication date. Relevant articles are presented.

RESULTS AND CONCLUSION

We propose a framework of attributes contributing to skin quality rooted in 3 fundamental categories—visible, mechanical, and topographical—with the aim to provide information to help guide clinicians and inform future clinical studies.

According to psychologist Nancy Etcoff,¹ identification of beauty is intuitive, whereas definition of beauty is subjective, mutable, and difficult to formulate into words. As the cornerstones of beauty include smooth, healthy looking skin, what comprises desirable skin is similarly difficult to define. Yet, flawless skin is an important component of facial attractiveness and continues to be one of the most universally desired features.^1–3 In a recent global survey, 94% of the 14,584 people interviewed desired to improve their facial skin, and terms such as radiance and healthy, glowing skin are requested by patients seeking improvements in their appearance (unpublished data, Allergan Aesthetics). The encompassing term for this collection of desired outcomes is skin quality.

Skin quality as a concept is gaining traction in the aesthetic field worldwide. Rejuvenation procedures, cosmeceuticals, and minimally invasive injectable therapies are increasingly popular. However, reaching a consistent, objective definition of skin quality has been difficult. Current literature focuses heavily on age-related changes in skin quality, rather than skin quality per se, and descriptive terminology has substantial variability between investigators and geographically (See Supplemental Digital Content 1, Table S1, http://links.lww.com/DSS/A795 for levels of evidence of included literature). The lack of a clear, comprehensive definition precludes identification of clinical indicators and evaluation tools necessary for proper assessment and treatment of undesirable skin quality. In short, skin quality has yet to be clearly defined. Thus, the authors' goal is to elucidate the importance of skin quality to patients and aesthetic physicians, explore and understand what factors comprise it, and identify the gaps in the authors' understanding. The authors then propose a novel classification of skin quality attributes to provide clarity for both patients and physicians.

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Importance of Skin Quality

Biological and Evolutionary Perspectives

The appearance of one's skin provides a wealth of information about an individual. Skin health is intricately linked to overall well-being, and clear skin is one of the body's “visual certificates of health,”¹ reflecting general health and vitality, as well as disease and nutritional state.^4–10 The visible condition of skin can also validate reproductive health and fertility.¹¹ Attributes of skin quality (e.g., texture and homogenous coloration) contribute to perceptions of facial attractiveness,² which may then correlate with mate choice and mating success,¹² potentially because of the condition of one's skin indicating the quality of his/her immune system.² Indeed, increasing evidence supports a link between immune health and facial attractiveness,^13–15 although more research is needed to fully understand the contribution of individual skin quality attributes to this relationship. In addition, men may perceive female skin as more attractive and healthier during the fertile (i.e., late follicular) phase of the menstrual cycle,^16–18 although data are equivocal and suggest minor variations in chromophore distribution could be the driver.