TRACEY DENNISON

THE SKIN QUALITY CONVERSATION

Tracey Dennison cuts through claims to clinical clarity

TRACEY DENNISON

Tracey Dennison is the consultant nurse practitioner at East Riding Aesthetics and Wellness, specialising in restorative and regenerative medical aesthetic treatments to give natural-looking, confidence-boosting enhancements. She has been nursing for over 30 years and is the Aesthetic Medicine Awards’ Nurse of the Year 2023.

Injectable “skin quality” work has become one of the busiest, noisiest corners of aesthetic practice. Patients are often very clear about what they want, yet the marketplace is saturated with products described as regenerative, biostimulatory, collagen-activating or “bio-revitalising”. Availability has expanded faster than our shared clinical language. The risk is that we compare treatments as if they are interchangeable, or we sell outcomes using vague biology rather than defensible clinical reasoning. In everyday practice, the aim is not to become a molecular biologist; it is to understand enough about what a material is designed to do in tissue so we can select it appropriately, sequence it sensibly, and explain it honestly.

In practical terms, most injectable skin quality options sit in three broad families. First are hydration-dominant injectables; non-crosslinked hyaluronic acid preparations delivered intradermally or very superficially to improve hydration, radiance and fine surface texture. Second are composite “biorevitalisers” or mesotherapy-style polycomponent formulations, combining hyaluronic acid with amino acids and/or antioxidant vitamins and cofactors, with the intention of supporting fibroblast function and matrix turnover. Third are DNA-derived restorative injectables – typically polynucleotides (PN) and polydeoxyribonucleotide (PDRN) – positioned as regenerative adjuncts, particularly for reactive or compromised skin. This grouping is clinically useful because it keeps us anchored in treatment intent: hydration and luminosity; metabolic support and substrate availability; or repair-oriented modulation of tissue behaviour.

The question I get asked most is, “Which one is best?” My answer is usually: best for which tissue problem, and for which patient, at which point in their treatment journey? Skin thickness, degree of laxity, inflammatory history, previous interventions, and tolerance for downtime all influence outcomes. Thin, crepey periocular skin behaves differently to thicker, sebaceous mid-face tissue. Photoaged, barrier-impaired skin behaves differently to dull-but-stable dehydration. If we are honest, a lot of perceived “product performance” is the performance of assessment, technique and sequencing.

Hydration-dominant hyaluronic acid skin boosters are often the most predictable starting point. The evidence base is imperfect but growing. A contemporary overview of injectable skin boosters describes hyaluronic acid as central to hydration-focused rejuvenation protocols, with benefits in radiance and biomechanical measures and generally favourable tolerability when delivered using microinjection approaches.2

In a prospective single-arm pilot study evaluating intradermal micropuncture injections of an HA-based gel, improvements were reported in parameters linked to ageing skin, and the authors concluded the approach was safe and effective as a “skin quality booster”, albeit with the limitations inherent to single-arm design.2

"These outcomes do not replace volumisation or lifting, but they can shift the overall skin read "

Particularly when patients present with dehydration, superficial roughness and loss of luminosity.

Composite biorevitalisers can feel more “active” to clinicians because they mirror what we understand about skin ageing: fibroblast function declines, oxidative stress increases, and substrate availability for matrix synthesis becomes a limiting factor. The rationale for polycomponent mesotherapy formulations is set out clearly by Prikhnenko, who argues that complex mixtures are intended to provide ageing skin with substrates key to fibroblast activity, and that clinicians benefit from understanding ingredient roles rather than treating these products as mysterious cocktails.3 Clinically, this group is often best framed as tissue conditioning rather than structural correction: gradual improvement in texture, fine crepiness and “tired” skin quality across a series, rather than immediate visible transformation after one session.

A helpful example of measurable outcomes comes from a 2024 study evaluating an intradermal hyaluronic acid complex supplemented with amino acids and antioxidant vitamins. The authors reported increases in hydration and viscoelasticity, increased skin density and microcirculation measures, and high participant satisfaction, while also noting limited change in wrinkle metrics over short follow-up.4 This pattern is familiar in practice: early wins are hydration, feel and light-reflection; deeper line change is slower and less reliable. If we frame these treatments as “wrinkle erasers”, we create frustration. If we frame them as improving the dermal environment and supporting healthier tissue function, patients tend to recognise the change more accurately and judge it more fairly.

THE PN/PDRN DEBATE

The most debated category in clinic at the moment is PN/PDRN. The published aesthetic literature is developing, and clinicians are rightly asking for clarity. A 2024 review in the International Journal of Molecular Sciences summarises current practices and perceived effectiveness, reporting use across facial rejuvenation, acne scarring and other indications, while stressing variable study quality and the need for further research to clarify optimal use.5 In other words: promising, but not settled science.

Where PN/PDRN often becomes clinically interesting is in phenotypes that do not simply need “more water”. Many of us see patients with reactive, inflamed, or stubbornly irregular texture, often alongside barrier disruption, rosacea-spectrum sensitivity, or post-inflammatory change. In those patients, hydration-only protocols can be short-lived. Expert clinical guidance has described PN use across hydration and rejuvenation, barrier-compromised inflammatory phenotypes, and scar remodelling, while still being explicit that the evidence base is limited and larger trials and histological validation are needed.6 That aligns with what many clinicians report: outcomes that feel more about resilience and surface stability than about “glow” alone, while also reminding us to stay cautious about over-claiming.

Mechanistically, the most clinically relevant summary is that PN/PDRN are proposed to support repair by influencing inflammatory balance and supporting regeneration/ angiogenesis in stressed tissue. A Frontiers in Pharmacology review describes PDRNassociated improvements in skin repair with increased vascular endothelial growth factor (VEGF) expression and notes that effects were abrogated by an A2A receptor antagonist in experimental settings, supporting receptor involvement.7 In a diabetic mouse wound model, PDRN was associated with angiogenesis and wound healing effects.8 These are not aesthetic trials, but they help explain why clinicians may see value in compromised or slower-to-recover tissue phenotypes.

Clinical evidence in aesthetic indications is emerging. A prospective randomised study in atrophic acne scars reported safety and effectiveness compared with placebo, while also calling for larger cohorts and longer follow-up.9 A PRISMA-aligned systematic review in the European Journal of Plastic Surgery identified heterogeneity and gaps in reporting of sequencing, targets and manufacturing standards, concluding that clinical integration should remain cautious and evidence-based.10 For day-to-day practice, that translates to careful patient selection and conservative claims.

So how do we build this into a usable clinical algorithm? I find it helpful to start with the dominant tissue need: hydration and luminosity; early crepiness; inflammation-linked texture instability; and scar remodelling. Hydration-focused hyaluronic acid microinjection protocols make sense when the skin is dehydrated, dull or superficially rough and the patient wants subtle improvement without volume. Composite biorevitalisers may be better positioned when the skin reads “tired” and thin, where substrate support and antioxidant environment might help across a series. PN/ PDRN may be considered where reactivity, barrier fragility, or post-inflammatory texture change are prominent, and where the goal is to support tissue steadiness and repair capacity, not simply to add hydration.

STABILISE FIRST

Sequencing is where outcomes become more consistent. A common mistake is to stack too many “regenerative” injectables too quickly, then struggle to interpret what is working (or provoking). Often, a better approach is to stabilise first; optimise barrier, settle inflammation triggers, and use hydration strategies if dehydration is present, then introduce a restorative injectable if the phenotype suggests it. This also protects consent.

Combination protocols are increasingly common, particularly PN alongside hyaluronic acid biorevitalisation. The rationale is plausible, meeting different tissue needs within one programme, but evidence for true synergy is limited. In practice, combinations should be treated as a structured programme rather than a “multiplier”. The basics still matter: conservative dosing, clean technique, aftercare, and documentation. While expert guidance notes a favourable tolerability profile for PN, it also reinforces that the evidence base is still limited and rare events cannot be fully excluded.1 Hyaluronic acid microinjection, while generally low risk, still carries the realities of injectable practice: swelling, bruising, transient papules and the requirement for anatomical respect.

"The stronger the marketing, the more important it is that we keep our patient counselling rooted in evidence strength and in realistic timelines. "

Finally, a note on anecdotal evidence, because it influences how patients shop and how clinicians talk. Anecdote is not evidence, but it is not meaningless either. It is a signal that helps us ask better questions: which phenotype responded, what was the protocol, what was the timeline, what changed in skincare or lifestyle, and what was the maintenance? The danger is when anecdote becomes certainty and is used to market absolutes. The responsible middle ground is to acknowledge what we see, articulate how confident we are, and keep our consent process aligned with the strength of the published literature.

CONCLUSION

The practical conclusion is that one category does not “win” overall, because these treatments are not all trying to do the same job. The market will continue to expand; our job is to ensure our clinical reasoning expands faster than the product catalogue.

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