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 1).
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.
1. Camouflage: This theme was named camouflage for the steps taken by the participants to try and ensure that others did not see their skin patches—applying heavy makeup or staying at home.
1.1 Heavy makeup: Most of the participants said that they needed to use multiple creams to hide their patches, and did not step out without makeup.
A 36-year-old housewife 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 housewife 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 housewife 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.
2.1 Treatment follow-up: All participants said that they had been taking treatment since long and following their physician’s instructions to treat the patches.
A 40-year-old housewife 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 nine months, adding that the patches may lighten but will reappear.
2.2 Hope for a cure: The participants spoke about their hope for a cure, saying that is why they continue with the treatment. A 45-year-old housewife said, “My family members discouraged me from seeking treatment as they thought I wouldn’t get better. Nonetheless, two months ago, I started the treatment. I feel that the patches have decreased since, which gives me hope. ”
Another said, “I hope these patches disappear someday. I’ve heard that the condition improves with age. I’m looking forward to that. ”
3. Lost beauty: The subthemes of mirror avoidance, regret over the loss of beauty, and disappointment were combined under this theme.
3.1 Mirror avoidance: Most of the participants said that they hated mirrors because these made them feel that they were no longer beautiful. The 36-year-old housewife said, “Now that my face is full of patches, I feel sad when I look in a mirror. So, I try to avoid it, because the more I look, the more upset I get.
Another housewife, 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. ”
3.2 The regret over the loss of beauty: Most of the participants were of the opinion that they were much better looking in the past and wanted to regain those looks. The 45-year-old housewife said, “I take my photo and I compare it with my old ones. I realize that I look aged.”
The 36-year-old housewife said, “When I look at old albums, I see that my skin was free of patches and acne. Now, it isn’t. ”
3.3 Disappointment: The participants who had been taking treatment for a long time reported feeling disappointed when they did not see the expected changes. A 42-year-old participant said, I’ve visited my physician often because of the patches but left disappointed; I stopped the drugs midway because the patches didn’t disappear quickly; they got worse. I expected to be cured within one to two months, but that didn’t happen. There is no cure. ”
The 40-year-old housewife said, “I’ve visited several physicians, even going to different cities for a consultation. They said that the patches wouldn’t go away for good, even if they did laser treatment.
Another participant said, “I took medication for a while, but whenever I missed a dose, the patches multiplied. I even tried to find other solutions like traditional medicine. Now, I’ve given up”
4. Grief: It was observed that when the participants realized that their condition was incurable, they accepted the loss of their beauty and grieved. This theme comprised the following three subthemes: a sense of guilt, depression, and low self-confidence.
4.1 A sense of guilt: The participants felt guilty about the patches. “When I was younger, I had a clear face. Sometimes I tell myself that these patches probably started because I applied so much cream back then. I wish I had taken better care of my skin in my youth
A 38-year-old clerk said, “I don’t feel relaxed in public, I feel embarrassed. I hold myself responsible for this ‘defect’ in me because I didn’t follow up on the treatment; I think this was treatable but I neglected it.
The 40-year-old housewife said, “I’m well aware of the fact that I didn’t eat properly. I had severe stress, didn’t sleep enough, and had been on antidepressants for a while—all of this caused this problem.
4.2 Depression: Depression is common among those facing appearance-related problems, and melasma patients are no exception. The 36-year-old housewife said, “I feel so old, I feel depressed, and when I look at my face in the mirror, I get upset.”
The 46-year-old housewife said, “I used to be so happy; now, every moment feels like a struggle. I’m always upset, depressed, and in a bad mood because of my patches. I don’t like to put on makeup either. I tell myself that my skin is terrible, so why bother with makeup anyway.
“I’m always in a terrible mood. I don’t feel like eating or doing any work” said a 38-year-old participant.
4.3 Low self-confidence: Similar to patients of other skin disorders, melasma patients too experience decrease in self-confidence. A 35-year-old housewife said, “I avoid talking when in a group. If I stay quiet, others may not pay much attention to me, and thus, not notice my patches.”
A 38-year-old teacher said, “I always feel despised; I don’t feel relaxed with my colleagues. I see these patches as a defect.”
“When I look in a mirror, I get upset. Moreover, sun exposure makes the patches darker. I’ve lost self-confidence—I apply powder even for going to the local grocery store” said a 32-year-old teacher.
5. Others’ reaction: This theme was derived from the subthemes of reduction in spouse’s affection, sarcasm, and feeling despised.
5.1 Reduction in spouse’s affection: Several of the younger participants with severe melasma expressed their feelings about decrease in their spouse’s affection toward them. A 37-year-old housewife said, “I feel my husband is overly conscious about my face when I don’t have makeup on; in fact, he doesn’t even come home at such times”.
Another said, “Though my husband hasn’t said anything openly, I feel that he is less affectionate toward me than before.”
5.2 Sarcasm: Some of the participants reported having to endure sarcastic comments from those around them. The 36-year-old housewife said, “My in-laws nag me saying I look aged and that there are many patches on my face. They even say ‘We didn’t look like this at your age.”
They behave terribly with me and treat me with contempt. They say it is too late for me to get treated for this because of my age.” Said the 45-year-old housewife.
5.3 Feeling despised: Besides other problems, the participants also felt despised by others. “Others’ opinion affects me. These days, women put in so much effort to look beautiful. When people see my face with patches on the forehead, they look surprised, as if they are wondering why I don’t try to look better.” said a 31-year-old housewife.
A 38-year-old housewife said, “People look at me as if I have a problem or defect, and this annoys me.”
“I don’t enjoy the company of people who stare at my patches,” said the 45-year-old housewife.