In search of lost beauty: Experiences of Iranian women with melasma

The skin condition called melasma affects patients' appearance significantly and affects them psychologically and emotionally, besides leading to an impaired body image.

or severe melasma, and all of them said that it affected their QoL and confidence, and therefore, the study concluded that physicians treating melasma should be aware of its psychological effects on the patients and the treatment's effects on their confidence. 6 In a qualitative study conducted to identify QoL impairments among pregnant women, the participants mentioned experiencing unpleasant skin changes, including acne, melasma, and striae, and some of them even felt ugly due to these. 7 Since access to quality information in different cultural environments is necessary to understand the psychosocial problems caused by melasma, and given the limited number of qualitative studies in this regard, the current study intends to value the singularity of the women with melasma, gives voice to the first-person viewpoint and shedding light on the experience of melasma as seen from inside, as it is lived by Iranian women with melasma, and, in this way, contributes to the construction of knowledge in the area of nursing in dermatology, based on the experiences of dermatological patients.

| MATERIAL S AND ME THODS
The content analysis method was employed for this qualitative study-qualitative content analysis is appropriate in cases of fewer theories or limited research on the phenomenon under investigation. 8 Twenty ‫‬ ‫‬ participants were selected through purposive sampling-the inclusion criteria were a melasma diagnosis confirmed by a dermatologist and interest in participating in the study.
Demographic information is listed in Table 1. The study setting was dermatology clinics affiliated with …. Face-to-face interviews were conducted in a room in the clinics for 25 to 35 min. At first, the general question, "How do you feel about melasma?" was asked, and later, for more information, questions such as "Why is it so?" and "What do you mean by this?".
In addition, phrases such as "Please explain further" were used.
All interviews were recorded with the participants' permission and then transcribed verbatim. Content analysis entails open coding, categorization, and abstraction. After reading the transcripts several times, the key concepts were underlined and the initial codes extracted. After extracting the codes from the sentences and paragraphs, they were merged into a series of subthemes based on the similarities and differences and then summarized under the main themes. The researchers tried not to impose their presupposition on the analysis as much as possible.
For consistency of data, transferability, credibility, and verifiability were checked. 9 For credibility, the researchers engaged with the data and participants continuously. For verifiability, the researchers benefited from the opinions of a colleague on the analysis of the data and codes; all activities were recorded and included in the final report for reliability.
Moreover, transferability was confirmed by sharing the study results with two contributors who were not involved in this research but had encountered a similar situation in their work.

TA B L E 1 Participant's demographics
objectives were shared with the participants, and they were assured that their information would be kept confidential and that they could leave the study at any time.

| RE SULTS
Initial coding gave 140 codes, and after removing repetitive ones, 114 were left. The final number of codes was 87 after omitting the extra and useless ones. Categorizing the initial codes gave 14 subthemes, which were classified into five themes; all five were then summarized under a general one, "in search of lost beauty" ( Table 2).

| The five themes
Below each of the five themes has been described in detail. The descriptions include the participants' thoughts, feelings, and responses recorded during their interviews. A 36-year-old homemaker said, "I never used to apply any cream, but now I apply several to conceal the patches-I can't go out if I don't do this because I'm afraid everybody will notice the patches.
Sometimes, even my husband tells me that my skin is no longer good and the patches are increasing. So, I have to have makeup on at home as well." A 35-year-old clerk said, "I spend half an hour applying makeup before going out; without it, I feel ugly. I think that if I went out without makeup, the neighbors would know my skin isn't good.
They've even told me that I look better when I've applied cream; that's why I never go out without applying it." 1.2. Avoidance: Most of the participants said that they went out less often, so that fewer people would see their patches.
A 35-year-old homemaker said, "I don't like going to public places.
For example, when I go to a party, everybody mentions the fact that my face is full of patches, and I feel embarrassed. So, I don't feel like going to parties." A 31-year-old homemaker shared the same feeling: "I don't like going to parties. My mom says it's ok, but my heart isn't in it. I haven't been to many parties because of the patches." 2. Seeking treatment: This theme was obtained by combining two subthemes-"treatment follow-up" and "hope for a cure" which was stated by all of the participants in the study.
2.1. Treatment follow-up: All participants said that they had been taking treatment for a long time and following their physician's instructions to treat the patches.
A 40-year-old homemaker said, "I apply the (therapeutic) creams every night even if I am pressed for time. I hope the creams make the patches disappear." A 32-year-old teacher said, "I've visited several physicians. Some prescribed combined medicines, while some said not to waste money on drugs because the patches reappear if one stops using the creams". Another said that "I should take medication under supervision for 9 months, adding that the patches may lighten but will reappear". Therefore, I try to avoid it, because the more I look, the more upset I get." Another homemaker, aged 46, said, "…I hardly ever look in a mirror, because seeing the patches upsets me; I feel sad and sorry for myself because of them.

| DISCUSS ION
This qualitative study revealed that melasma affects patients' lives significantly. Data analysis gave five themes: camouflage, seeking treatment, lost beauty, grief, and others' reaction. Finally, all five were summarized under a general one, "in search of lost beauty." Some of the themes found in the current study were consistent with those in previous studies which were descriptive and investigated melasma's effects on patients' QoL, self-esteem, and self-confidence, indicating that the condition has significant psychological, emotional, and social impacts on patients, who also have to spend a lot on its treatment, though the results do not always meet their expectations.
For example, a study on melasma perception of 70 patients in Iraq concluded that the condition had detrimental effects on TA B L E 2 Themes and subthemes in the experience of women with melasma in Iran  10 Therefore, it seems the key theme "in search of lost beauty" presents an appropriate and realistic concept for dermatologists to focus on when considering female melasma patients' life problems.
This study had a few limitations that any qualitative research is bound to have and the results may not be generalizable. In addition, this study was conducted in an urban population, which may not be representative of the general population.
Furthermore, the researchers investigated the experiences of women who had volunteered to participate in the study; these might be different from the experiences of those who were unwilling to take part or of men.

| CON CLUS ION
As the results of this study showed, melasma has a profound impact on patients' QoL-the study participants did not want to leave home, felt despised, were preoccupied with their patches and lost beauty, and avoided the mirror. Therefore, therapists, as well as treatment, should focus on melasma's social and psychological aspects.

ACK N OWLED G M ENT
We thank all interviewees who agreed to take part in the study to share their invaluable experiences.

CO N FLI C T O F I NTE R E S T
The authors declare that there is no conflict of interest.

E TH I C S S TATEM ENT
The project is accepted by the Ethics Committee of Ardabil University of medical sciences, and informed consent was taken from all participants in this study.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available in request.