Meanings of quality of life for patients with facial melasma

1Universidade Estadual Paulista “Júlio de Mesquita Filho” – Faculdade de Medicina de Botucatu – Departamento de Enfermagem – Botucatu/SP – Brazil. 2Universidade Estadual Paulista “Júlio de Mesquita Filho” – Faculdade de Medicina de Botucatu – Departamento de Dermatologia e Radioterapia – Botucatu/SP – Brazil. Autor correspondente: Silmara Meneguin | Universidade Estadual Paulista “Júlio de Mesquita Filho” – Faculdade de Medicina de Botucatu – Departamento de Enfermagem – Av. Professor Montenegro, s/n | ZIP Code: 18618-000 – Botucatu/SP – Brazil | E-mail: silmeneguin@fmb.unesp.br Received: Jul. 07, 2018| Accepted: Oct., 1


INTRODUCTION
Melasma is a common, chronic, recurrent pigmentary abnormality characterized by asymptomatic and symmetrical hyperpigmented macules on the skin, particularly on the face.It occurs due to local hypermelanogenesis and a ects millions of people around the world 1 .It usually occurs in one of three clinical patterns.e most common is the facial center, while the less common types are malar and mandibular 2 .
Women in fertile age are the most affected and photoexposed areas are the most a ected, especially the face 3 .Melasma a ects all ethnicities and populations, but epidemiological studies indicate a higher prevalence among more pigmented phenotypes, such as East Asians ( Japanese, Koreans and Chinese), Indians, Pakistani, people of the Middle East and Mediterranean Africa.In the Americas, it is common for Hispanics and Brazilians that live in intertropical regions, where there is greater exposure to ultraviolet radiation 1,4 .Genetic predisposition may be noted with the high incidence of family history of melasma among patients with the disease.In a Brazilian study with 302 women with facial melasma, there was a reference of 47.6% of rstdegree relatives a ected 5 .
Melasma is a disease that is generally di cult to treat, with a long course and frequent exacerbations that may in uence patients' perception of quality of life 6 .
Quality of life (QoL) is de ned by the World Health Organization (WHO) as the individual's perception of their position in life in the context of the culture and value systems in which they live in relation to their goals, expectations, standards and concerns 7 .
In the context of the clinic, it is related to the repercussion or treatment of diseases that may in uence the perception of the concept.In this sense, the impact of the disease on patients' QoL is being increasingly emphasized in therapeutic clinical trials as a relevant outcome 8 .
In the clinical patient, dermatoses can a ect selfimage and have great potential to unleash processes that a ect self-esteem, contributing to cause feelings that can manifest as anxiety, sadness or even depression.It is known that the intensity of the injury in the QoL is proportional to the time that the a ected person coexists with the melasma 9 .
However, little emphasis has been given to the subjective perception of the individual with melasma in
Meanings of quality of life for patients with facial melasma relation to their QoL.Most of the studies realize evaluation of the construct through psychometric instruments 10 .
us, this research intends to value the singularity of the individual with melasma and, in this way, contribute to the construction of knowledge in the area of nursing in dermatology, based on the experiences of dermatological patients.

OBJECTIVE
To exhibit the meanings attributed to QoL by patients with facial melasma.

METHODS
A descriptive, exploratory study with a qualitative approach, realized in a public university hospital in the interior of the state of São Paulo and in a private clinic of the same municipality in March 2014.
Patients with melasma in clinical treatment and older than 18 years were established as inclusion criteria.
After this step, ve patients were randomly selected from the list of patients attending the research sites, and then the invitation to participate in the focus group was realized.is method was chosen because it is a technique used to obtain data from previously planned discussions in which the participants express their experiences, values, beliefs and attitudes about speci c issues 11 .
In this method, the discussion should be conducted by a moderator for approximately 2 hours in a private setting 11 .e recording of the discussion is realized by an observer who is in charge of monitoring the recording equipment, in an agile and discreet way, aiming not to shift the group's attention to their movements.Also make a brief record in each speech of the participants, to facilitate the later transcription 12 .
Sociodemographic data were collected by means of an instrument developed for the study and obtained from records of medical forms.In the sequence, the focal group was realized, having like guiding questions: 1) In your opinion, does the melasma interferes in the QoL?
and 2) Do you think that melasma interferes in which aspects of QoL? e speeches were recorded and later transcribed using the content analysis of Bardin 13 .In this technique, after the literal transcription, the pre-analysis is realized, the content organization phase, whose purpose is to systematize the ideas to proceed with the exploration of the material that essentially involves the categorization operation.Finally, in a third moment, data analysis and interpretation occurs.

RESULTS
Ten patients, all womene, with a mean age of 47.3 years, participated in the study.Of these, ve come from private clinics and the other half from the public hospital.
As for schooling, ve have a medium level, four upper level and only one fundamental level.
To better understand the results, the units of meaning were grouped into three themes: physical aspects/ appearance, clinical treatment and social/emotional aspects with their respective categories.Participants (P) are identi ed in the text with the numbering assigned to them in the focus group transcript.
From the rst theme, physical aspects/appearance, the categories emerged: curious and malicious questions about the blemish, di culty hiding the injury and appearance of uncared skin.
In the interviewees 'speech, the annoyance generated by the opinion of others, with curious and even malicious questions related to the blemish, can be perceived, since the visible aspect of the skin injuries and their psychological impact interfere in the patients' QoL 14 .
I had the unhappiness of a person speaking: "do you not shave the fuzz?".(P1) Hey, you never go to the dermatologist!(P2) e biggest embarrassment is the person asking you: "About that blemisht, do you not do anything for it?".(P3) Di culty in concealing the blemish and appearance of skin neglect also cause distress, as participants report that it is very di cult to nd a product that completely covers the blemish, resulting in a careless appearance of skin.
Pollo CF, Miot LDB, Miot HA, Meneguin S Some authors describe that skin injuries on the face are more noticeable to the vision of other.erefore, the visual appearance will play a fundamental role in the perception of oneself 15 .
I already went to do makeup and the person to turn and speak: "there is no way, there is no way to hide".(P2) I'm going to put something on my face and accentuate the blemish a thousand times more, you can not hide, right?(P5) In the second theme, the clinical treatments mentioned by the participants, from which the following categories emerged: annoyance with the sunscreen, the treatment itself to lighten the blemishes and the cost of the treatment.
Care with the disease and its treatment also represent di culties that can impair leisure and work activities 16 .
e participants reported dissatisfaction with the sunscreens available in the market due to the fact that they did not have good coverage; due to the texture of the product does not allow adequate absorption, leaving the skin looking greasy and smeared; and, lastly, because they are not suitable for the skin of Brazilian women, since most of these products are imported The sunscreens, it are for the European women, e bleaching treatment itself also generates discomfort and impacts on the QoL of the participants.Some patients reported not adhering to the treatment in the summer because it is so strong that, in addition to leaving the skin red, burned and there is a greater risk of darken the blemish again, the creams used in the treatment dirty and even damage the bedding.In the third theme, the social and emotional aspects were revealed with their respective categories: annoyance with the veiled look of the other, with photographs and the own image when looking in the mirror.
In a society that values the beautiful and has preestablished esthetic standards, the skin can be considered a business card that attracts, thus, the critical and demanding looks of individuals.When intact and healthy, the skin promotes the relationship between people and facilitates their development in social, emotional and sexual aspects.
However, when it is a ected by cutaneous a ections, it can have serious consequences 17 .
e impression is that people are talking to us and looking straight into it, even if they do not realize it.(P2) We have the feeling that people are looking at the blemish, not for us, not in people's eyes.The opinion of others does not bother me much, no.I think it's more when I look in the mirror myself.(P3)

DISCUSSION
The results indicate that melasma is a frequent dermatosis and, because it affects exposed areas, producing the aspect of carelessness and being difficult to camouflage, maximizes its impact on body image and interpersonal relationships.Studies show that patients suffering from this disease feel bored, less attractive and use cosmetics to cover blemishes 18 .
The patient believes that people focus on their skin instead of paying attention to what it is saying, which compromises social and leisure activities.Thus, it is possible to affirm that melasma generates a great impact on the QoL of these patients, since it is a chronic dermatosis and sometimes stigmatizing 19,20 .
Although most dermatological patients do not have fatal diseases, dermatoses often have a major impact on the emotional state, social relations and daily activities of patients, the stigmas caused by very apparent manifestations 21 .
Skin diseases impair self-image and have the potential to lead to depression and anxiety as well as serious systemic diseases.Although not fatal or physically debilitating, they can seriously affect the psychological and social functions of individuals 22 .
In this sense, as a person perceives physical changes in their appearance, this condition can cause suffering and alterations in their life, implying losses in daily routine, socialization and losses in general.Sociological and psychological data increasingly indicate that skin problems can have serious consequences, as they generate shame, anxiety and social embarrassment 23 .
The banalization of the problem can be understood in the light of the traditional educational training in health: the biomedical model.Founded on simplistic and reductionist thinking, it leads the student to a fragmented view of the complexity of life 24 .Studies point out the obstacles of the team in transcending the limits set for their performance 25 .
A study evidences the necessity for education processes directed to health teams focused on the evaluation of melasma, considering that it is a problem of low morbidity, but that it impacts women's QoL 25 .
Melasma causes a negative impact on QoL, mainly due to the face and body image.Due to the dissatisfaction with the appearance, the patients show compromised selfesteem, with repercussions in personal and professional life 23 .
A recent study with a qualitative approach points to data that corroborate the findings of this research 26 .
Because they are apparent, dermatoses easily affect the personal, professional and social life of their patients.
In view of this, it is necessary to value the subject aiming at the global evaluation of these individuals.
The lack of studies evaluating the perception of QoL from the perspective of patients was a limitation to compare the findings of this study.

CONCLUSION
Because it mainly affects the face, which makes it easily visible, melasma bothers and has a negative impact on QoL because it affects patients' psychological and emotional well-being.
Discourses point out that QoL is a subjective conception, linked to values and influenced by the repercussions of the health-disease process in all its dimensions.This fact refers to the necessity not to consider this condition only an esthetic problem.
In this context, nursing can make an important contribution to its action in integral health care, expanding its field of vision and giving meaning to the other's issues as a unique person with their own needs and expectations.

I
do not do the treatment in the summer.I walk, I do not have a car, and I'm afraid of getting more blemished if I continue the treatment in the summer.(P3) My blemish got worse with the treatment in the summer.By the way, my husband charges me: "but you did it wrong!".(P6) e smell bothers me, you're going to give your husband a kiss, you're all stinky.(P7) It is strong, it even erodes the pillowcase, and the blemish does not pull.(P4) I had a huge allergy to hydroquinone.(P5) Skin treatment is very expensive.(P3) I nd it very expensive.(P2) Sunscreen even if you go to see how much you spend per month ... (P6) (P4) e picture is very dark.(P3) When you look in the mirror, you only see the blemish, the rest nothing else catches your attention.(P5) Meanings of quality of life for patients with facial melasma