The Science and Evolutionary Perspective of Beautiful Skin

Abstract

Quality skin has long been a symbol of health and attractiveness, reflecting both genetic and environmental influences. Multiple elements contribute to beautiful skin. This complex topic influences modern dermatological practices and skincare approaches. This article reviews and explores the characteristics that define beautiful skin, integrating physical attributes with the scientific foundations that underpin them. It also delves into the evolutionary significance of skin appearance and the impact of visible skin conditions on social and psychological well-being. Additionally, it reviews advances in dermatological treatments and preventive measures aimed at achieving beautiful skin.

1. Key Points

Beautiful skin has long symbolized health and attractiveness, reflecting both genetic and environmental influences.

• Smooth texture indicates well-maintained keratinocyte turnover and balanced stratum corneum function.
• Skin firmness relies heavily on collagen and elastin, whose age-related decline leads to sagging and wrinkles.
• A radiant complexion indicates healthy blood flow and adequate cellular renewal. Diet, hydration, and sleep significantly contribute to maintaining skin radiance.
  Skin hydration affects both appearance and function, as adequate water content maintains elasticity and reduces fine lines.
• Clear and healthy-looking skin is often perceived as a sign of good health and fertility, playing a key role in mate selection.
• Healthy skin can influence social interactions and status perception, contributing to success in various social contexts.
• Skin conditions can deeply impact self-esteem, especially in social environments that emphasize appearance.
• Chronic skin conditions can cause physical discomfort, lifestyle limitations, and emotional distress, significantly affecting quality of life.
• Advances in topical treatments such as retinoids and corticosteroids, as well as laser therapies, have revolutionized the management of skin disorders.

2. Introduction

In modern dermatology, the characteristics and qualities of the skin are central topics during consultations, as the skin functions not only as a physiological organ but also as a visual marker of an individual’s health; when altered, it can negatively impact both physical and emotional well-being [1,2]. From a scientific and evolutionary perspective, beautiful skin can be defined as skin that exhibits signs of good health and youth [3] and is characterized by several interrelated attributes: homogeneous pigmentation, radiance, smooth and uniform texture, elasticity and firmness, adequate hydration, and the absence of inflammation or visible lesions [4,5,6,7].

Evolutionary medicine examines how the human body is the result of millions of years of adaptation to selective pressures, whose primary goals have been survival and reproduction [8]. The skin has also been part of this process, adapting to fulfill essential functions of protection, regulation, and signaling. Its present-day features are the outcome of various evolutionary processes, including natural selection, genetic drift, population bottlenecks, and genetic admixture [9,10]. Cutaneous traits have been shaped by a complex interplay of evolutionary pressures, particularly ultraviolet (UV) radiation, vitamin D synthesis, and folate protection, leading to different pigmentation patterns that vary with latitude [9,11,12,13,14].

Evolutionary models of skin pigmentation highlight the fundamental role of melanization in survival and reproduction. One such model proposes that melanin protects folate, a vitamin essential for purine and DNA synthesis critical processes for reproduction and embryonic development but highly sensitive to the damaging effects of UV radiation [9,12,15]. Thus, more pigmented skin protects both genetic integrity and fertility by reducing UV-induced DNA damage, particularly in tissues such as the skin and reproductive organs [9,12,13].

This process helps explain why skin pigmentation varies by latitude: in equatorial regions, where UV exposure is highest, darker skin provides more effective protection [9]. In contrast, in regions farther from the equator, selective pressure shifted toward maximizing vitamin D synthesis, also dependent on UV radiation, thereby favoring the evolution of lighter skin to facilitate this process [11]. In this balance, the diversity of human pigmentation can be interpreted as the outcome of two opposing evolutionary forces: one promoting photoprotection and the other favoring vitamin D synthesis [9,11,12,13]. Another important shift in the evolution of human skin was the reduction in body hair, associated with the adoption of bipedalism. This posture decreased the body surface directly exposed to the sun, reducing the need for extensive hair coverage as a barrier against UV radiation. However, scalp hair was retained, as it protects one of the areas most exposed to radiation: the top of the head [16]. Just as skin evolved in response to environmental and reproductive pressures, so too have our perceptions of attractiveness. The perception of facial attractiveness has played a central role in human sexual selection, serving as a filter for choosing partners with greater reproductive potential [17]. In this sense, aesthetic preferences are not random but rather function as external signals guiding social and reproductive decisions [17,18,19]. Preferences for what constitutes an attractive face tend to favor individuals more likely to transmit good genes and ensure the survival of offspring [17,18,19].

Conversely, visible skin alterations such as acne, vitiligo, melasma, or scarring can markedly reduce perceptions of facial attractiveness both by others and by the affected individual [20,21], thereby interfering with the visual cues that have historically facilitated mate selection and, consequently, reproductive success. Several studies have demonstrated that these conditions negatively impact self-esteem, generate emotional distress, and affect quality of life, not only for functional reasons but also due to their social and symbolic burden [22,23,24,25]. A review of the available evidence on the defining characteristics of beautiful skin and its evolutionary basis, as well as whether this concept helps explain the psychosocial burden of visible dermatological conditions, reveals that scientific literature on this topic remains limited.

3. Objective and Methodology

This article aims to describe the characteristics that define healthy or beautiful skin, their evolutionary implications, and the relationship between the absence of these traits and the psychosocial impact of dermatological diseases. A literature search was conducted in PubMed and Google Scholar for studies published between 1 January 2000, and 31 July 2025. The exact search terms used, either alone or in combination with Boolean operators (“AND”, “OR”), were “skin physiology”, “skin aesthetics” OR “skin beauty”, “skin pigmentation”, “evolutionary biology AND skin”, “reproductive health AND skin”, and “cosmetics AND skin”. This search initially yielded approximately 70 abstracts. After removing duplicates and screening for relevance, around 45 full-text articles were reviewed in detail and included in the narrative synthesis. Given the exploratory and descriptive nature of this work, the purpose was not to perform a systematic quantitative analysis but to provide a broad overview of the current evidence on the physiological, aesthetic, and psychosocial dimensions of healthy skin.

4. Results

4.1. What Is Beauty?

The concept of beauty has been the subject of reflection since Antiquity and has been approached from various perspectives. In classical philosophy, beauty was considered more than an aesthetic quality; it was regarded as a concept that transcends the physical [26,27,28]. Plato (427–347 BC) viewed beauty as an ideal form or perfect archetype. For him, beauty was a manifestation of the divine and the good, and the experience of beauty connected the soul to the eternal and ideal world. In The Symposium, he suggested that the contemplation of beauty guides the soul toward truth and virtue [26]. Aristotle (384–322 BC), by contrast, defined beauty in terms of harmony, proportion, and order. According to Aristotle, what is beautiful is that which conforms to certain rules of symmetry and proportion that elicit pleasure in the observer [27]. In modern philosophy, Immanuel Kant (1724–1804) proposed that beauty is a subjective experience that nonetheless has universal communicability. In his Critique of Judgment (1790), he argued that although aesthetic judgment is subjective, there is a general agreement on what is considered beautiful [28].

A mathematical manifestation of the aesthetic ideal is the golden ratio, recognized since antiquity as a universal principle of harmony [29]. The Greek sculptor Phidias (490–430 BC) was among the first to employ this proportion, also known as phi, the Fibonacci ratio, or the divine proportion, which has long been considered a universal arithmetic model in aesthetics [29]. In the study of human beauty, Marquardt conducted a cross-cultural, modern, and historical analysis, concluding that facial beauty is associated with the presence of golden ratios [29]. However, recent studies indicate that there is no solid evidence to support this as a universal formula for human beauty [30,31,32,33]. Three-dimensional analyses have shown that some horizontal facial proportions approximate phi, but most evaluated proportions deviate significantly from this value, even in subjects regarded as attractive [34]. Facial beauty, therefore, appears to be more strongly influenced by overall harmony, symmetry, and proportion of features rather than by similarity to the golden ratio [35,36]. Furthermore, recent studies have demonstrated that the applicability of these concepts is limited and may vary significantly across different ethnic groups and genders, underscoring the importance of avoiding rigid application of these beauty canons [37].

From an evolutionary perspective, Charles Darwin defined beauty as a phenomenon with biological function within the framework of sexual selection. In The Descent of Man and Selection in Relation to Sex (1871), Darwin proposed that many traits considered beautiful such as bright colors, symmetry, or ornaments evolved because they were preferred by the opposite sex during mate choice. He extended this idea to humans, suggesting that preferences for certain physical attributes may have arisen as signals of health and fertility [38]. Thus, beauty is seen as an adaptive tool guiding reproductive behavior.

Finally, from a scientific standpoint, beauty can be understood as a set of physical traits that elicit positive responses such as attraction or aesthetic appreciation [39]. According to Rhodes, features considered beautiful such as facial symmetry, youth, or certain secondary sexual characteristics are indicators of good genetic and reproductive health and therefore may have evolved as criteria for mate selection [18]. Although there are universal components, perceptions of beauty are also influenced by social, economic, and cultural values [40]. Despite repeated attempts to quantify facial beauty using proportions or symmetry, no objective and universally applicable set of criteria have yet been established [39].

4.2. Charactertistics of Beautiful Skin

From a dermatological and evolutionary perspective, skin considered “beautiful” is defined as that which reflects health, youth, and vitality [5,41]. Humphrey et al. explored the known and unknown factors that comprise skin quality, proposing three fundamental categories of attributes: visual (visible), mechanical (skin movement), and topographical (tactile). Visual attributes include pigmentation and symmetry. Mechanical attributes encompass elasticity, firmness, thickness, and tension. Finally, topographical attributes involve smoothness, roughness, fine lines, wrinkles, and the presence or absence of enlarged pores [4]. Skin appearance plays a critical role in modern dermatology. These characteristics are summarized in

Table 1. Characteristics that make for healthy or attractive skin.

Category	Characteristics	Associated Factors
Visual	Uniform color, absence of blemishes, radiance, and a healthy tone.	Skin hydration, balanced diet, adequate sleep, and regular exfoliation.
Mechanical	Elasticity, firmness, thickness, and ability to return to its original shape.	Collagen and elastin, proper hydration, and optimal barrier function.
Topographical	Smooth texture, absence of fine lines, reduced pores, and uniform surface.	Balanced cell turnover, exfoliating products, and sun protection.
Pigmentation	Uniform pigmentation, avoiding dark spots or hyperpigmentation.	Adequate sun protection, antioxidants, and management of conditions like melasma.
Luminosity	Naturally glowing skin with a healthy appearance.	Proper blood flow, consumption of fruits and vegetables rich in carotenoids.
Symmetry	Facial symmetry, free of visible scars or skin alterations.	Corrective treatments such as lasers, chemical peels, and proper scar management.
Hydration	Soft and elastic skin, without signs of dryness.	Use of moisturizers, adequate internal hydration, and products rich in glycerol and hyaluronic acid.
Evolutionary Impact	Appearance of health and fertility: clear skin, free of imperfections, and lower androgen levels.	Biological signals such as low androgen levels and high estrogen levels, reflecting good general health.

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4.2.1. Pigmentation: Uniform Tone and Homogeneity

A uniform distribution of melanin and hemoglobin produces an even skin tone, free of spots or hyperpigmentation, which is associated with perceptions of health, youth, and attractiveness [5]. A slightly yellowish hue, primarily due to the accumulation of carotenoids derived from fruit and vegetable intake, is perceived as healthier. Similarly, cheek redness is also perceived as healthier, as it indicates underlying vascularization and oxygenation [42,43]. Among visual attributes, uneven pigmentation as seen in photoaging and melasma, redness, and dullness are associated with the loss of natural radiance and a sallow complexion [4,44,45].

4.2.2. Hydration, Elasticity, and Firmness

Well-hydrated skin appears smoother, more translucent, and less rough. Hydration reduces surface light scattering, enhances penetration, and creates a rosier, more translucent appearance, all of which are associated with healthy-looking skin [46]. Elasticity, firmness, thickness, and tension are also influenced by hydration, which impacts both the appearance and function of the skin. Adequate water content maintains elasticity and minimizes fine lines [47]. Proper hydration is essential for preserving barrier function. In addition, proteins such as collagen provide tensile strength, and elastin allows the skin to return to its original shape after stretching; the degradation of these proteins leads to visible signs of aging [48]. Firmness depends on both collagen and elastin, which provide structural support; their age-related decline results in sagging and wrinkle formation [49].

4.2.3. Texture: Smoothness and Roughness

Smooth skin and the absence of visible fine lines or wrinkles also signal a healthy and aesthetically pleasing appearance [50]. Smoothness is regarded as a marker of youth [4,51]. Since the skin serves as an effective barrier between the body and the environment, a smooth texture reflects adequate keratinocyte turnover and balanced stratum corneum function, maintained by regular exfoliation and hydration [52,53].

4.2.4. Radiance and Translucency

Radiant skin is defined as a subtle and even reflection of facial light that conveys youth and attractiveness. Unlike matte or greasy shine, radiance is perceived as healthier and more attractive, especially when evenly distributed across the face or concentrated in the cheeks and T-zone [46,54]. A luminous complexion indicates healthy blood flow and adequate cell renewal; factors such as diet, hydration, and sleep significantly contribute to maintaining radiance [55]. In a study involving 160 women who evaluated attractiveness under seven skin-reflection conditions including three types of reflectance (radiant, oily/shiny, and matte) and three facial zones (full face, cheeks only, and T-zone only) faces with radiant reflection across the full face were rated as younger and more attractive compared with those with oily or matte finishes [46]. Other studies have shown that decreased radiance correlates with higher perceived age [56] and increased activation of the medial orbitofrontal cortex in observers, a brain region associated with attractiveness judgments [57].

4.2.5. Absence of Visible Lesions

The absence of inflammation or visible lesions is indispensable, since the presence of erythema, papules, or pustules alters aesthetic perception and may be associated with disease [5,41]. The absence of visible lesions is therefore an essential attribute in the definition of beautiful skin, as it reflects an adequate state of skin health. A surface free of erythema, papules, pustules, or scarring signals the absence of inflammatory processes and thus an intact skin barrier, which is unconsciously interpreted as a marker of good general health and low pathological burden [58,59].

4.2.6. Is Healthy Skin the Same as Beautiful Skin?

The concepts of healthy skin and beautiful skin are related but not equivalent. Healthy skin is characterized by intact physiological functions such as an effective barrier, adequate hydration, competent immune defense, and the absence of infections or active inflammatory processes [53,60]. By contrast, beautiful skin is a perceptual construct that combines scientific, evolutionary, and sociocultural criteria, defined by the visible attributes described above: even color, radiance, smoothness, firmness, and absence of lesions, which are interpreted as signs of youth and attractiveness [5,21]. The differences between healthy and beautiful skin are summarized in

Table 2. Difference between a healthy skin and beautiful skin.

Aspect	Healthy Skin	Beautiful Skin
Definition	Skin with preserved biological functions: barrier, immunity, hydration, and wound healing.	Skin that reflects health, youth, and perceived attractiveness, evaluated by visible criteria.
Focus	Medical.	Scientific, evolutionary, and sociocultural.
Main Criteria	Absence of infection, active inflammation, or severe barrier dysfunction.	Even pigmentation, radiance, smooth texture, firmness, hydration, and absence of visible lesions.
Relationship to Health	Physiological state of the cutaneous organ.	Indirect perception of health and fertility.

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5. Skin Appearance and Reproductive Potential

Skin appearance provides relevant visual cues about health and well-being. In humans, skin tone enriched with carotenoids (yellowish or reddish, derived from diet) is associated with visual perceptions of health and facial attractiveness, and it correlates with indirect indicators of physical well-being, such as good cardiovascular fitness and lower body fat percentage [42], as well as with a slightly elevated immune response. Experimental studies have demonstrated causality: beta-carotene supplementation increases skin redness and yellowness, enhancing visual perceptions of health and attractiveness [61]. From an evolutionary perspective, diet-induced carotenoid pigmentation is also considered an honest signal in sexual selection, since species with color vision, such as humans, can discriminate subtle variations in skin tone [55]. This coloration is perceived as a visual marker of health and attractiveness, even more so than melanin tanning, suggesting that skin color may play an adaptive role in mate choice [62].

Similarly, certain skin traits function as biological signals of health and fertility, particularly relevant in sexual relationships and mate selection. In women, several studies have demonstrated that higher perceptions of facial attractiveness are associated with elevated estradiol levels, a hormone linked to ovulation and fecundity [63,64]. Conversely, higher levels of anti-Müllerian hormone (AMH) have been negatively correlated with perceptions of facial attractiveness. One study evaluated the correlation between AMH, a marker of ovarian reserve and predictor of reproductive longevity, and perceptions of facial attractiveness. Results showed that women with higher AMH levels tended to be perceived as less attractive, while facial attractiveness was associated with higher estradiol levels, a marker of current fecundity. This may reflect a possible biological trade-off between present fecundity and reproductive lifespan, where facial traits associated with higher fecundity (elevated estradiol) are evolutionarily preferred, even if they may be linked to reduced reproductive longevity (lower AMH) [65]. These findings support the hypothesis that skin and facial traits can act as visible indicators of fertility, influencing mate choice and, consequently, reproductive success [63,64,65].

In the case of acne, a chronic inflammatory condition that typically appears during puberty and adolescence, it coincides precisely with the onset of sexual maturity [6]. This condition negatively impacts skin appearance and reduces attractiveness at the very time when individuals begin seeking partners. Some authors suggest that acne signals the onset of reproductive availability, even if it does not represent optimal skin health, potentially functioning as a communicative role indicating that a threshold of biological maturity has been reached [66]. In this sense, the resolution of acne by the end of adolescence may become an even stronger signal of health and full reproductive maturity [66].

Other visible dermatological diseases such as psoriasis, urticaria, eczema, hidradenitis suppurativa, chronic skin infections, or blistering diseases can also significantly affect quality of life, impacting body image, self-esteem, interpersonal relationships, and sexual life [67,68,69]. In this context, negative body perception may act as a barrier to intimacy, reducing opportunities for emotional or sexual interaction and thereby indirectly interfering with reproductive behavior. Studies on quality of life and sexuality in dermatological patients show that these skin conditions can reduce both the frequency and satisfaction of sexual activity [69,70].

6. Impact of Visible Skin Diseases

Chronic conditions such as acne, hidradenitis suppurativa, psoriasis, atopic dermatitis, vitiligo, and alopecia areata increase the risk of depression, anxiety, and reduced quality of life [1]. In addition, alterations in skin integrity can generate physical symptoms such as itching and pain, directly affecting daily activities and comfort, thereby further diminishing quality of life [1,71]. Beyond physical symptoms, these conditions frequently carry social stigma, evoking feelings of insecurity, shame, and social withdrawal [72,73,74]. Multicenter- and population-based studies report that most patients with chronic skin diseases experience stigmatization and social rejection, unpleasant looks, derogatory comments, isolation, and difficulties in personal and work life, significantly impacting mental health and social integration [72,73,74]. In a study of 300 patients, 65% reported feeling distressed about their appearance most of the time, 57% felt ashamed, and 42% stated it interfered with their interpersonal relationships. Additionally, 43% felt less attractive or even dirty. Interestingly, disease severity assessed by clinical scales did not correlate with the impact on quality of life [75]. In melasma, a common acquired chronic hypermelanosis, significant impacts have been reported on appearance, self-esteem, psychosocial and emotional well-being, and overall quality of life [24]. A study using the Melasma Quality of Life Scale (MelasQoL) in 30 patients with varying severity (MASI score) found no significant differences between MelasQoL results and MASI scores, suggesting that some individuals perceive the disease as more severe than clinical scales indicate [24]. Regarding pigmentary changes, a cross-sectional study using the Vitiligo Quality of Life Scale (VitiQoL) in 573 patients reported an average score of 38.4 ± 11.8, with higher scores among those with disease duration of more than 5–10 years, involvement of exposed body areas, multiple sites, or rapidly progressive disease [25].

With respect to scarring, acne scars negatively affect psychosocial well-being in proportion to their severity. A study of 723 patients with acne scars but no active lesions reported an average Dermatology Life Quality Index (DLQI) score of 6.26; 16.9% exhibited clinical signs of body dysmorphic disorder, 68% experienced embarrassment or insecurity, and 74.8% worried their scars would never disappear [22]. Surgical scars, particularly facial scars, are also associated with high levels of anxiety and low self-esteem due to perceived social stigma [23]. Not all individuals with skin diseases experience the same degree of emotional impact. Various individual and contextual factors influence this, including age, gender, personality, and personal history [76]. For example, a study of patients from diverse social and ethnic backgrounds in South Africa found that women were more likely than men to report effects of skin disease on self-esteem, clothing choices, treatment difficulties, and anxiety [76]. Contextual factors include disease duration and extent: the more visible and chronic the condition, the greater the impact [76].

7. Modern Dermatological Strategies to Improve Skin Quality

Dermatologists currently have various preventive and therapeutic options to improve skin appearance, such as chemical peels, laser therapy, and oral medications or supplements. However, routine skincare practices also remain fundamental in achieving healthy and beautiful skin.

7.1. General Care

Hygiene: Daily cleansing should be performed with gentle products of physiological pH (5.5) and free of harsh detergents, avoiding excessive washing to prevent disruption of the lipid mantle and skin barrier [53].

Hydration: Regular use of emollients containing ceramides or hyaluronic acid is recommended, as they restore epidermal lipids and prevent transepidermal water loss, thereby reducing the risk of eczema, xerosis, and premature aging [7].

Photoprotection: Daily and repeated use of broad-spectrum sunscreen (SPF ≥ 30) is essential. Broad-spectrum filters (UVA, UVB, visible light) prevent photoaging (wrinkles, solar elastosis, pigmentary changes) and DNA damage and have been shown to reduce the incidence of basal cell and squamous cell carcinoma [77].

Nutrition: Balanced nutrition and adequate systemic hydration play a critical role in maintaining skin health. Among key micronutrients, vitamin C acts as a cofactor in collagen synthesis and as a water-soluble antioxidant that neutralizes free radicals [78]. Vitamin E, the main lipid-soluble antioxidant, protects cell membranes from lipid peroxidation and, together with vitamin C, contributes to endogenous photoprotection [79]. Carotenoids (β-carotene, lycopene, lutein) accumulate in the skin and function as antioxidant filters, reducing UV-induced erythema and delaying photoaging [80]. Polyphenols from green tea, cocoa, and flavonoid-rich fruits exert anti-inflammatory and antioxidant effects, inhibiting matrix metalloproteinase activation that degrades collagen and favoring repair of solar damage [81].

Systemic hydration: Adequate systemic hydration contributes to maintaining barrier function and improves parameters such as elasticity and skin smoothness, particularly in individuals prone to dry skin [82].

7.2. Chemical Peels

A chemical peel consists of applying a chemical agent to the skin to induce controlled damage to the epidermis (and sometimes dermis). This controlled injury promotes regeneration and remodeling, improving skin appearance and texture [83]. It can restore a youthful look to the aged face, neck, and hands, and treat medical conditions such as acne, melasma, photoaging, pigmentary disorders, and acne scars [84]. Benefits depend on peel depth (superficial, medium, deep) and the agent used. Superficial and medium peels, such as glycolic acid or trichloroacetic acid (TCA), offer favorable risk–benefit profiles with lasting results and fewer serious complications. Deeper peels, such as phenol, produce more dramatic and long-lasting changes but carry greater risks and require close monitoring [85]. Limitations include difficulty in controlling penetration depth, increasing the risk of complications such as scarring, infection, post-inflammatory hyperpigmentation, and, rarely, systemic toxicity [85,86].

7.3. Laser Therapy

Laser therapies deliver controlled high-intensity light energy to the skin to induce changes in the epidermis and dermis [87,88]. They stimulate dermal remodeling through collagen and extracellular matrix synthesis, improving firmness, elasticity, and texture, and reducing wrinkles and pigmentation related to photoaging [89]. For rejuvenation and skin quality, lasers are categorized as ablative (e.g., CO₂, Er:YAG), which vaporize controlled layers of epidermis and dermis, and non-ablative, which induce dermal thermal damage without disrupting the epidermis. Both can be fractionated, creating microthermal zones surrounded by healthy tissue, enabling faster recovery and reduced complication risk [88,89,90]. Fractional CO₂ lasers have shown efficacy in improving photoaging and skin texture [91] and are useful in pigmentary disorders such as melasma [92], acne scars, and traumatic scars [93]. Er:YAG lasers are effective for skin rejuvenation, improving texture, dyschromia, actinic damage, and other conditions [94]. Considerations include variable efficacy depending on lesion type, skin phototype, and treatment depth [95]. Adverse effects, particularly with ablative lasers, include erythema, pain, edema, blistering, crusting, infection, post-inflammatory hyper- or hypopigmentation, and scarring [96].

7.4. Topical Therapy

Topical retinoids, particularly retinoic acid and tretinoin, remain the gold standard for improving skin texture, pigmentation, and elasticity, with robust evidence supporting their use in rejuvenation [97]. However, they must be used cautiously in sensitive skin and higher phototypes due to irritation risk [97,98]. In this context, the principal adverse effects are pruritus, burning, erythema, peeling, and photosensitization [99]. It is because of this that patients using topical retinoids should avoid excessive sunlight and use photoprotection. No systemic side effects on long-term treatment have been reported, but still, the FDA recommends discontinuing and avoiding the use of topical retinoids during pregnancy [97,98,99].

Tranexamic acid (TXA) corresponds to a plasmin inhibitor that can be used orally, topically or intralesionally. Its main use in dermatology is to treat hyperpigmented disorders, such as melasma. Its mechanism is focused on inhibiting UV-induced plasmin activity and suppressing stimulating paracrine factors produced by melanocytes [100]. The side effects depend on its presentation; oral TXA can produce gastrointestinal effects, menstrual alterations, deep vein thrombosis, pulmonary embolism, acute renal critical necrosis, and acute myocardial infraction. Topical presentation can cause cutaneous xerosis, irritation, and desquamation. And intralesional TXA injections can cause bruising, erythema, pain in the site of administration, and hypopigmentation [100]. Hydroquinone, a tyrosine-kinase inhibitor that blocks the melanin synthesis pathway, is used in dermatology to treat different dyschromia such as melasma, solar lentigines, freckles and post-inflammatory hyperpigmentation. It is used topically in concentrations between 2 and 4% [101]. Multiple studies have shown that the best therapeutic efficacy is achieved when hydroquinone is combined with a retinoid and a corticosteroid, and the most prescribed is the triple combination cream Triluma (R), that contains 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide [102]. The side effects include erythema, xerosis, burning, dermatitis, and less frequent ocrhonsis [103].

Other topical options commonly used by dermatologists include niacinamide, vitamin C, glycolic acid, azelaic acid, salicylic acid, and topical antioxidants such as vitamins, polyphenols, and flavonoids [104]. Niacinamide is recommended for improving barrier function, reducing inflammation, hyperpigmentation, and redness [98]. Topical antioxidants such as vitamin C and polyphenols protect against oxidative damage and improve radiance and tone [97]. Exfoliating acids (alpha-hydroxy acids such as glycolic, beta-hydroxy acids such as salicylic) are useful for epidermal renewal, treatment of uneven texture, and hyperpigmentation, though they should be avoided after ablative procedures and used with caution in higher phototypes [97]. Other consensus ingredients include azelaic acid, peptides, and hyaluronic acid for hydration and extracellular matrix support [98,104,105].

7.5. Oral Medication

Systemic treatment with isotretinoin, a retinoid indicated for severe acne [106], has shown significant improvements in skin quality in terms of wrinkles, texture, and color. One study demonstrated that all patients treated with oral isotretinoin experienced improvements in wrinkles, skin thickness and color, pore size, elasticity, and tone, along with reductions in pigmented lesions and mottled hyperpigmentation [107]. However, evidence regarding the broader benefits of oral isotretinoin remains controversial [108]. The main side effects are mucocutaneous dryness (e.g., cheilitis, xerosis, epistaxis, dry eyes, erythema, desquamation, pruritus, among others), musculoskeletal alterations (e.g., myalgia, arthralgia, arthritis, increases in CPK, among others), elevation of transaminases and triglycerides, acne flare-up, and teratogenicity [109]. Other oral options that have been mentioned in the literature are gingko biloba, green tea extract, resveratrol, centella asiatica, and tea tree oil; these have shown promising effects such as antioxidant and anti-inflammatory agents, but most studies have limitations and further research with big groups of patients and longer follow-up periods are needed to validate these results [110].

7.6. Oral Photoprotection

Oral photoprotection, as recently described, involves supplementation as an adjunct to topical sunscreens. It modulates oxidative stress and UV-induced pro-inflammatory mechanisms; supplementation with various compounds can regulate and neutralize reactive oxygen species, providing benefits for skin protection [111]. Substances with antioxidant, photoprotective, and anticarcinogenic properties include vitamins C, D, and E; nicotinamide; plant extracts (Polypodium leucotomos, Camellia sinensis); polyphenols (cocoa, turmeric); carotenoids (β-carotene, lycopene, astaxanthin); and afamelanotide [111]. Multiple studies show that higher concentrations of these molecules improve skin conditions. A study evaluating β-carotene supplementation at 30 and 90 mg/day demonstrated prevention and repair of photoaging, improving the appearance of wrinkles and facial elasticity [112]. Another study found that patients with higher cutaneous antioxidant levels had fewer wrinkles and furrows and less roughness compared with controls [113].

7.7. Topical Photoprotection

Photoprotection is essential and should include the daily use of broad-spectrum sunscreens (UVA/UVB), universally recommended for preventing photoaging and hyperpigmentation, as well as for protection against visible light in higher phototypes using mineral or tinted sunscreens [44]. Photoprotection is the most evidence-based intervention for preventing decline in skin quality and extrinsic aging [97].

7.8. Biostimulators

Biostimulators have gained prominence in recent years for their ability to improve skin quality progressively and sustainably. These substances stimulate collagen and elastin production, leading to increased firmness, elasticity, and dermal density, while reducing fine wrinkles and improving overall appearance [114,115].

The most used biostimulators include calcium hydroxyapatite (CaHA), poly-L-lactic acid (PLLA), and polycaprolactone (PCL). In addition to their initial volumizing effect, they induce persistent neocollagenesis, visibly improving skin texture and radiance [116,117].

The choice of biostimulator should be based on patient characteristics, treatment area, and therapeutic goals. For example, CaHA has proven effective for improving facial laxity and lower-face quality [118], while PLLA has been widely used in the malar and temporal regions for its ability to gradually induce type I collagen [119].

8. Youth Beyond Biological Age

All current aesthetic treatments, by enhancing visible attributes of the skin such as color uniformity, radiance, and firmness, allow the perception of youth to extend beyond actual biological age. This phenomenon not only alters how signs of aging are perceived but can also modify social and mating dynamics by simulating characteristics traditionally associated with fertility and reproductive health [41,59]. From an evolutionary perspective, young and healthy skin has historically functioned as an honest marker of biological value; however, contemporary aesthetic interventions act as “masked signals” that prolong the appearance of vitality and attractiveness beyond natural limits [5,120].

Although these interventions can improve self-esteem and quality of life, they also generate unrealistic social expectations and aesthetic pressure. The rapid advancement of aesthetic medicine has contributed to the idealization of flawless skin, free of wrinkles or imperfections—an unattainable goal from a biological standpoint [41,120]. This pursuit of standardized beauty may lead to dissatisfaction, dependence on repeated procedures, and even psychiatric disorders such as body dysmorphic disorder, in which subjective perception of appearance is severely distorted [121]. In this sense, aesthetic medicine faces the ethical challenge of balancing real psychological benefits with preventing aesthetic pressure and the reinforcement of unattainable beauty ideals [122].

9. Discussion

Skin appearance plays a critical role in modern dermatology. The reviewed literature suggests that healthy-looking skin is associated with reproductive success [63,64,65], highlighting its relevance within the evolutionary processes that have shaped human skin. Skin appearance conveys information about health and well-being, and certain traits such as diet-induced carotenoid pigmentation are perceived as signals of health and attractiveness, playing a role in sexual selection [57,61]. Likewise, some cutaneous attributes signal biological fertility, particularly in women, where facial attractiveness is associated with higher estradiol levels [61,62,63]. This supports the idea that facial and skin traits act as indicators of fertility and reproductive potential, influencing mate choice.

Conversely, chronic dermatological diseases such as acne, psoriasis, atopic dermatitis, vitiligo, alopecia areata, and hidradenitis suppurativa affect not only physical health but also mental health and quality of life [70,71,72,73,74,75,76]. These conditions often generate social stigma, leading to shame, insecurity, isolation, and low self-esteem, which negatively impact sexual life and interpersonal relationships, and ultimately perceived reproductive success [67,68,69,70,71,72,73,74,75,76]. From this perspective, aesthetic preferences are not purely cultural; rather, they fulfill an adaptive role, guiding mate choice toward individuals perceived as healthier and more fertile, thereby increasing reproductive success. This is reinforced by subtle visual cues, such as facial skin quality, which we unconsciously associate with youth, absence of disease, and hormonal balance. Thus, visible imperfections such as severe acne, hyperpigmentation, or scarring may (often erroneously) be interpreted as signs of poor health, diminishing attractiveness, and mating opportunities.

In response, modern dermatology has developed a wide therapeutic arsenal to improve skin quality. Strategies such as chemical peels, laser therapy, retinoids, antioxidants, and oral photoprotection help enhance skin quality [82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119], positively influencing personal and social perceptions of individuals with visible skin conditions. However, these treatments can also prolong the perception of youth and simulate signals of health and fertility beyond biological age [41,59]. While they may improve self-esteem, they also generate unrealistic beauty expectations and risk of dissatisfaction, raising an ethical challenge for aesthetic medicine [120,122]. No evidence was found directly linking improved patient quality of life with an evolutionary factor. However, it is hypothesized that the psychological impact of visible conditions such as melasma, vitiligo, and scarring may result from how they disrupt attributes such as symmetry, uniform pigmentation, texture, elasticity, and radiance. This is supported by observed improvements in quality of life among patients undergoing dermatological treatments for aesthetic purposes. For example, a study of 120 patients undergoing chemical peels for medical and cosmetic reasons employed the Rosenberg Self-Esteem Scale before and after treatment. It found that these patients had lower self-esteem compared to controls and demonstrated a significant post-procedure increase: from 18.97 ± 3.36 to 22.83 ± 3.34 in cosmetic cases, and from 21.58 ± 3.20 to 23.48 ± 2.43 in patients with dermatological disease [123].

This opens the possibility for future studies integrating the attributes that define high-quality skin as therapeutic objectives in the clinical management of dermatological conditions. Such an approach would allow evaluation of how improvements in these attributes contribute to enhanced self-perception, higher self-esteem, and better quality of life in patients.

10. Conclusions

According to the reviewed literature, what is considered attractive skin can be understood as part of evolutionary processes through which our skin reflects health and reproductive potential. Furthermore, the psychosocial impact of imperfections and dermatological diseases appears to be linked to how alterations in pigmentation, spots, or scars disrupt attributes such as symmetry, uniform color, and texture, which are considered attractive. However, further research is needed to deepen our understanding of the origins of these perceptions and the accompanying social stigma.