Beauty Sleep: What Your Tired Face Says About You

Abstract & Commentary

By Barbara A. Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington. Dr. Phillips is a consultant for Cephalon, and serves on the speakers bureaus for Resmed and Respironics.

Synopsis: Sleep-deprived individuals appear less healthy, tired, and less attractive to untrained observers than when they are rested.

Source: Axelsson J, et al. Beauty sleep: Experimental study on the perceived health and attractiveness of sleep deprived people. BMJ 2010;341:c6614; doi: 10.1136/bmj.c6614.

In this study, investigators photographed the faces of 23 adults (mean age, 23 years; 11 women; mostly college students) in the middle of the afternoon under two conditions: 1) after a normal night's sleep (at least 8 hours between 11 pm and 7 am, thus after about 7 hours of wakefulness); and 2) after sleep deprivation (sleep between 2 and 7 am one night, and then an entire night of sleep deprivation, thus after about 31 hours of wakefulness). Smokers, recent alcohol drinkers, and people with sleep disorders and complaints were excluded.

Participants slept in their own homes, and sleep times were confirmed (and enforced) with sleep diaries and text messages. Participants were instructed not to nap. During the normal sleep condition, the participants' mean estimated duration of sleep was 8.45 hours. The sleep deprivation condition started with a night of sleep restriction, estimated to be 5.06 hours on average, followed by a night of total sleep deprivation, which was monitored in a sleep laboratory.

For the photo shoot, participants wore no makeup, had their hair loose (combed backwards if long), underwent similar cleaning or shaving procedures for both conditions, and were instructed to "sit with a straight back and look straight into the camera with a neutral, relaxed facial expression." They were kept indoors 2 hours before being photographed to avoid the effects of exposure to sunlight and the weather. The photographer was not blinded to the sleep conditions, but followed a highly standardized procedure during each photo shoot, including minimal interaction with the participants. Each participant had a series of 5-6 photographs taken in a well lit room, with a constant white balance under each condition. The focal length and the distance from camera to head were fixed. A blinded rater chose the most typical photograph from each series. This resulted in 46 photographs, one from each sleep condition of each of the 23 participants.

The photographs were presented randomly at a fixed interval of 6 seconds to 65 observers (40 women; mostly students; mean age, 30 years), who were unaware of the conditions of the study. They rated the faces for attractiveness, health, and tiredness on a 100 mm visual analogue scale (VAS). After every 23 photographs a brief intermission was allowed, including a working memory task intended to prevent memorization of the faces by the observers. To ensure that the observers were not primed to tiredness when rating health and attractiveness, they rated the photographs for attractiveness and health in the first two sessions and tiredness in the last.

When sleep deprived, people were rated by the observers as less healthy (mean, 63 vs 68), more tired (53 vs 44), and less attractive (38 vs 40) than after a normal night's sleep. Compared with the normal sleep condition, perceptions of health and attractiveness in the sleep-deprived condition decreased on average by 6% and 4% and tiredness increased by 19% (all statistically significant).

In addition, perceived attractiveness was positively associated with perceived health and negatively with perceived tiredness, and there was a strong negative association between the perceptions of tiredness and health.


About once a month, a writer for a women's magazine contacts me to find out "the truth" about beauty sleep. Thus, I have had occasion to pore over the internet, looking for peer-reviewed and/or scientific data on this topic. While it has been speculated that adequate sleep is part of good skin care,1 this issue simply hasn't been studied. Until now. The current study confirms what we knew intuitively: We look better when we have slept enough. And it may be that sleep duration, while important, is not the complete recipe for a healthy appearance. Sleep quality may matter as well. Recent work indicates that the microvascular effects of obstructive sleep apnea may also contribute to premature aging.2

Most of us spend a large percentage of our time trying to get patients to eat less, exercise more, quit smoking, and generally change behavior. Getting adequate sleep should be on the list of behaviors that we include in our instructions about healthy living. And not just because we humans look better when we sleep well. Short sleep has been associated with everything from obesity to death.3-5 Sleep deprivation also impairs judgment and cognitive function. Indeed, it has been recently suggested that surgeons who are sleep-deprived notify would-be surgical candidates of this fact to allow them to give well-informed consent;6 the current study suggests that patients could simply tell by looking.

A quarter of a century ago, credible reports linked cigarette smoking to ugliness,7 and "smoker's face" is now a well-recognized clinical entity. Perhaps "sleepless face" will join the ranks of clinical findings that we can employ in our efforts to motivate behavior change in patients.


1. Kahan V, et al. Can poor sleep affect skin integrity? Med Hypotheses 2010;75:535-537.

2. Yim-Yeh S, et al. Obstructive sleep apnea and aging effects on macrovascular and microcirculatory function. Sleep 2010;33:1177-1783.

3. Gangwisch JE, et al. Short sleep duration as a risk factor for hypertension. Hypertension 2006;47:833-839.

4. Qureshi AI, et al. Habitual sleep patterns and risk for stroke and coronary heart disease: A 10-year follow-up from NHANES I. Neurology 1997;48:904-911.

5. Buxton OM, Marcelli E. Short and long sleep are positively associated with obesity, diabetes, hypertension, and cardiovascular disease among adults in the United States. Soc Sci Med 2010;71:1027-1036.

6. Nurok M, et al. Sleep deprivation, elective surgical procedures, and informed consent. N Engl J Med 2010;363:2577-2578.

7. Model D. Smoker's face: An underrated clinical sign? Br Med J (Clin Res Ed) 1985;291:1760.