Skip to main content

Comparison of generic and specific instruments to assess the quality of life in patients with melasma



To compare the psychometric performance of a generic and specific instruments in assessing melasma-related quality of life.


A cross-sectional study was conducted with 150 patients with melasma attending an outpatient dermatology clinic of a public hospital in São Paulo state, Brazil. Data were collected using a questionnaire containing sociodemographic and clinical data as well as the generic WHOQOL-BREF, and the dermatological-specific Skindex-16 and HRQ-Melasma.


The overall internal consistency of the domains of the three instruments was ≥ 0.7. A strong positive correlation was identified between the Skindex-16 and HRQ-Melasma domains (0.68-0.78). Item-response theory showed that most Skindex-16 and HRQ-Melasma domains were more informative than WHOQOL-BREF.


The three instruments for assessing QOL tested presented good psychometric performance, with satisfactory internal consistency values. Only the two dermatological instruments, however, demonstrated a strong correlation between the domains that assess social, emotional, and functional aspects of QOL, indicating that both were able to identify impairments in other QOL dimensions in addition to the physical domain.

Peer Review reports

Key Points

  • WHOQOL-BREF and the dermatological-specific Skindex-16 and HRQ-Melasma showed good psychometric performance with satisfactory internal consistency values.

  • Only the dermatological-specific instruments tested showed strong correlation between the domains that assess the social, emotional, and functional aspects of quality of life, highlighting their sensitivity to identify impairments in quality of life domains other than the physical domain.

  • Specific multidimensional instruments should be used to assess skin disorders related quality of life, when available.

  • Skindex-16 and HRQ-Melasma showed superior information on items in most domains.


Melasma is a pigmentary skin disorder characterized by the presence of hyperchromia, asymptomatic and symmetrical macules in the skin [1, 2]. These macules molecules are formed due to local hypermelanogenesis and typically appear on the face in central locations such as cheeks, chin, nose, and upper lip [3]. In addition, it can occur in other visible body parts such as the neck and upper limbs [2].

Although the exact prevalence of melasma is unknown, several factors have been linked to the development of such macules, including exposure to ultraviolet rays, genetic predisposition, phototoxic drugs, pregnancy, and the use of oral contraceptives [4, 5]. Thyroid issues are also mentioned in the literature as a possible risk factor for melasma [3]. However, because it usually appears after periods of sunlight exposure, it is thought that contact with solar radiation is one of the primary factors in its development [6]. Furthermore, women of reproductive age are the most affected by melasma, indicating that sexual hormones play a decisive role in the pathophysiology of the disease [7, 8].

Although this disease is not physically debilitating, contagious, or life-threatening, evidence shows that melasma has a negative impact on patients' quality of life [9, 10]. This is due to the impairment of appearance when manifesting itself in highly visible places, which can affect self-image, self-esteem, and contribute to the development of negative feelings [11, 12].

According to a study conducted in Latin America, most patients affected by melasma had psychiatric disorders, with depression being the most common [13]. The World Health Organization (WHO) defines quality of life (QOL) as an individual's assessment of his or her own life in relation to his or her goals, expectations, standards, and concerns while considering the cultural context and the values in which it is embedded [14]. Therefore, understanding QOL is critical to comprehend a patient's state of health [3], as it may not be limited to the severity of the disease or the intensity of the lesions [15]. Consequently, using generic or specific instruments that perform the most reliable QOL measurement becomes increasingly important [16].

Generic instruments, such as WHOQOL-BREF, address multidimensional aspects of a patient's life, such as social integration, physical security, mobility, and body image, and can be applied to healthy persons or people affected by a disease [14, 17]. There are also generic instruments for specific health conditions, such as the SKINDEX-16, a generic dermatological tool used in individuals with skin disorders [18]. In contrast, disease-specific instruments focus on a specific area of interest, detecting biological and psychosocial aspects of a specific condition. For the purpose of this study, the HRQ-Melasma was selected to assess the disease-specific QOL as this instrument was developed specifically for individuals with melasma [1]. The advantage of these instruments is that they are sensitive enough to detect specific aspects of a disease's impact on the QOL [19].

For instruments to be recognized as scientifically robust, they must provide accurate, valid, and interpretable data [20]. The quality of the information they provide is largely determined by their psychometric properties, which are measured by their reliability and validity [21, 22]. However, there is a lack in the dermatological literature of studies comparing generic and specific QOL instruments aiming to understand the informative gain in the QOL assessment. Another gap in knowledge relates to the lack of research comparing the performance of a specific against a generic skin disorder QOL instrument to assess the real benefit of using such instruments. As melasma is common in clinical practice, we decided to use the available multidimensional instruments i.e. HRQ-Melasma, Skindex-16, and WOOQOL-BREF.

Therefore, the main aim of this study was to compare the psychometric performance of generic and specific melasma-related quality of life instruments to contribute to the advancement of knowledge in this field. We hypothesized that specific instruments are more sensitive in assessing dermatological related QOL.


This was a cross-sectional study with 150 melasma patients attending the dermatology outpatient clinic at the Clinical Hospital of the School of Medicine, São Paulo State University (UNESP), Brazil.

The following eligibility criteria were adopted: patients of both sexes with melasma clinically diagnosed by a qualified dermatologist, aged 18 or older in outpatient care, emotionally capable of responding to the questionnaire, and who agreed to participate in the research. Participants who did not complete the data collection instrument were excluded.

Each participant completed their questionnaire in a private room, individually. The research team clearly stated that refusing to participate in the study would not jeopardize the continuation of their treatment. Data collection occurred between November 2017 and December 2018 using a questionnaire consisting of sociodemographic data, WHOQOL-BREF, Skindex-16, and HRQ-Melasma.

Generic and specific quality of life instruments

WHOQOL-BREF is a generic instrument that contains 26 items addressing four domains of a patient's life, including physical, psychological, personal relationships, and the environment. The responses are based on a Likert scale of 1-5, with regards to severity in the past two weeks, with the higher score indicating a higher quality of life [23] Table 1.

Table 1 Domains and items of the WHOQOL-BREF

The Skindex-16 is a multidomain instrument in which answers are given on a 7-point Likert scale, ranging from 0 (never bothered) to 6 (always bothered), based on how often a patient was worried by their skin condition over the previous seven days. It consists of 16 items that encompass three domains: symptoms, emotions, and functionality. All responses are transformed on a linear scale ranging from 0 to 100 points. Scores for each of the three domains are calculated. A higher value indicates a lower quality of life. This instrument has been translated and culturally adapted for use in the Portuguese language [18].

The HRQ-Melasma is a specific instrument to assess the QOL of people suffering from melasma [1]. It has 19 items and reports on the following dimensions: physical/appearance, social/professional, psychological, and treatment [1]. Responses are given on a 5-point Likert scale, ranging from 0 (never applies) to 4 (always), based on how often a patient felt upset or had his routine altered by the males in the last 30 days. Individuals are categorized into the following categories: <15 (not affected); 16-35 (slightly affected); 36-50 (moderately affected); 51-65 (very affected); >65 (extremely affected) [1].

The average time to complete the questionnaire was 20 minutes. All instruments were answered within this time.

Statistical analysis

Initially, all variables were analyzed descriptively. The score of each of the instrument domains was assessed according to their median, 25th and 75th percentiles (p25 and p75), since they were not normally distributed (Shapiro-Wilk test, p<0.05).

The alpha coefficient of Cronbach's alpha was used to assess internal consistency and values greater than 0.7 [24] were considered significant. The Spearman coefficient was used to analyze the correlation between instrument domains, and it should be greater than 0.7 to indicate a strong correlation [25].

The information in the construct domains was evaluated using the Multi-Array Item Response Theory, and values above 1.2 [26] were considered appropriate. This test was performed using the R software, mirt package. The other analyses were carried out using the IBM SPSS program, version 25. The level of significance adopted was 5%.

The sample size was calculated using the recommendation of a minimum sample size of 150 participants for Item Response Theory-based psychometric studies [27].

The Research Ethics Committee approved the project of the Sao Paulo State University (Protocol no 2.392.601), and the participants signed a written term of free and informed consent. We confirm that all methods were performed in accordance with the relevant guidelines and regulations.

This manuscript followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [28].


The final analytical sample comprised 150 patients with melasma, since there was no refusal. Overall, there were 147 (98%) female participants, with an average age of 41.8 (±8.7) years. Most were married/living with a partner, had a higher level of education, and had a monthly household income between $191 and $570. Most patients reported that they worked indoors, i.e., without sun exposure.

Their occupation types included nursing technician, shop assistant, cleaner, and household service manager. Most participants have been in treatment for between one and five years, and the average age of melasma emergence was 29.9 years (±8.4). In terms of lifestyle, 15% said they were smokers, and 64% drank alcohol. The average body mass index (BMI) was 26.2 (±5.5) kg/m2, indicating overweight (Table 2).

Table 2 Sociodemographic and clinical characteristics of the participants (=150)

The median (p25-p75) score for each of the WHOQOL-BREF, Skindex-16, and HRQ-Melasma domains are presented in Table 3. The physical domain of WHOQOL-BREF had the highest median (3.9), followed by the emotional domain on Skindex-16 (81) and the psychological domain of HRQ-Melasma [19]. These parameters indicate that quality of life was regular in the physical domain of WHOQOL-BREF, worse in the emotional domain on Skindex-16 and slightly affected in the psychological domain of HRQ-Melasma.

Table 3 Distribution of the median score of the WHOQOL-BREF, SKINDEX-16, and HRQ-Melasma domains

Table 4 shows the internal consistency values of the WHOQOL-BREF, Skindex-16, HRQ-Melasma domains. It is noted that for all three instruments analyzed, all areas had satisfactory internal consistency (>0.7). In WHOQOL-BREF, the psychological domain had the highest Cronbach alpha value (0.87), and the domains personal relations and environment had the lowest (0.80). For Skindex-16, the domains with the highest internal consistency were the emotional and the functional (0.93), while physical had a lower consistency (0.79). Finally, in HRQ-Melasma, the psychological domain was the most consistent (0.95). However, the treatment had the lower consistency (0.81).

Table 4 Internal consistency (Cronbach alpha) for WHOQOL-BREF, SKINDEX-16, HRQ-Melasma domains

Correlations between the domains of WHOQOL-BREF, Skindex-16, and HRQ-melasma are presented in Table 5. The domains that are shared by all instruments were chosen for this analysis. The environment domain of WHOQOL-BREF cannot be correlated with any other field because it addresses aspects of a patient's life that are not assessed by the other instruments. Similarly, the HRQ-Melasma treatment domain is also not represented in the other questionnaires and hence, not included in the analysis.

Table 5 Spearman correlation coefficients (p-value) among SKINDEX-16, WHOQOL-BREF, HRQ-Melasma and their domains

The negative correlations values of WHOQOL-BREF dimensions are due to the reverse direction of the magnitude of the scale. The correlations values between WHOQOL-BREF's domains and Skindex-16 and HRQ-Melasma were the lowest ones. The physical domain correlated poorly with the physical domain of Skindex-16 (-0.31) and did not correlate with the physical domain/appearance of HRQ-Melasma (-0.24). The correlation between the area personal relations with the functional and social/professional obtained coefficients of (-0.30) and (-0.26), respectively, showing a negligible correlation. The psychological domain correlated with the emotional domain of Skindex-16 (-0.37) and the psychological domain of the HRQ-Melasma (-0.40), indicating a weak correlation in both.

When comparing the physical domain of the two dermatological instruments tested, HRQ-Melasma and Skindex-16, there was a weak correlation (0.31). However, there was a strong correlation (0.80) between the emotional domain of Skindex-16 and the psychological domain of the HRQ-Melasma. Similarly, the functional domains of Skindex-16 and social/professional of HRQ-Melasma showed a strong correlation (0.78).

The informative level of the WHOQOL-BREF, Skindex-16, and HRQ-Melasma domains according to the Item Response Theory is shown in Table 6.

Table 6 Item response theory for WHOQOL-BREF, SKINDEX-16 and HRQ-Melasma

We found that the physical, psychological, and environmental domains of WHOQOL-BREF, as well as the physical from Skindex-16, did not provide adequate information based on the information corrected by the number of items (values below 1.2). HRQ-Melasma, on the other hand, has shown satisfactory results in all areas.


To the best of our knowledge, this is the first study to compare generic and specific instruments for assessing melasma-related quality of life. Our main findings showed that specific instruments, in addition to the physical domain, have greater sensitivity to identify impairments in other quality of life domains.

Although melasma can affect both sexes, the literature indicates that its prevalence is higher in women of reproductive age due to the activation of melanocytes by female sexual hormones [4, 29], which is consistent with the findings of this study.

In the present study, the comparative analyses of the three QOL instruments was based on internal consistency, validity and item information using the Item Response Theory. The item information was the most relevant aspect for the present analysis since the available evidence shows that responsiveness, a measure of longitudinal validity, is not always considered by all researchers to be a psychometric property. However, current definitions highlight the importance of such measure to assess the validity of changes in score of an instrument [30,31,32].

On the other hand, in the Item Response Theory, standard responses of an individual to a particular group of items provide the base to estimate the latent traits, by allowing a better use of the information gathered. This approach allows not only the classification of individuals in relation to their latent traits but also to collect information on an instrument as a whole and, particularly, item by item [33]. The Item Response Theory should not be seen as a method to replace the classic theory but as a complementary analytical tool [34].

In terms of Skindex-16's consistency, our study found consistent values for all domains, with higher emotional scores (0.93). Cronbach alpha was 0.86, 0.93, and 0.88 for the Physical, Emotional, and Functional domains, respectively, in a study using Skindex-16 in patients with various dermatoses [18].

The HRQ-Melasma instrument demonstrated high internal consistency in the development study, with values of 0.88, 0.91, 0.93, and 0.73 for the areas of Physical/Appearance, Social/Professional, Psychological, and Treatment, respectively [1]. Similarly, the present study observed Cronbach's alpha above 0.7 for these domains and the psychological domain with a higher coefficient (0.95). This study found that the domain with the highest Cronbach alpha value was related to psychological aspects, in addition to reaffirming significant internal consistency in the three instruments evaluated. This supports the notion that melasma is a disease that significantly impacts self-image, as evidenced by the literature [1, 3].

The WHOQOL-BREF' Personal Relations' and 'Environment' domains, on the other hand, had the lowest Cronbach alpha values. This could be attributed to the low sensitivity of this instrument in detecting the social and environmental impacts on melasma. The physical domain of Skindex-16 also supports the notion that melasma is a disease with a low physical impact that poses no threat to the patient's life [1]. However, when comparing the internal consistency of the physical domains of the three instruments analyzed, we found that HRQ-Melasma shows the highest Cronbach's alpha, demonstrating that a specific instrument has a greater correlation between the items in the domains, making its internal consistency higher and with this, increasing its capacity to perceive the inconvenience caused by the melasma.

Regarding instrument correlation, there is a scarcity of comparative studies between generic and specific instruments in the dermatological research area. The lack of correlation between WHOQOL-BREF, Skindex-16, and HRQ-Melasma highlights the fact that WHOQOL-BREF did not capture the impact of melasma on quality of life as well as the other instruments. This can be attributed to the fact that WHOQOL-BREF is a generic instrument for several areas, with no questions directed toward melasma. Therefore, systemic conditions may outweigh the conditions affected by dermatosis.

A strong correlation was found between the emotional and social domains of Skindex-16 and HRQ-Melasma. This indicates that both instruments managed to capture the inconvenience caused by melasma in these aspects. However, there is no correlation between the physical domains of the instruments, indicating that melasma has physical implications that are not consistent and vary greatly between patients [35].

Concerning the information on the items that comprise the three instruments, we found that the generic instrument, i.e., WHOQOL-BREF revealed domains that were less informative than the others, indicating its reduced capacity for capturing the true impact of melasma on one's quality of life. However, in comparing common domains between the three instruments tested, such as the Psychological WHOQOL-BREF, Emotional of Skindex-16, and Psychological of the HRQ-Melasma, the greatest level of information came from Skindex-16. Similarly, for the Personal Relations area of WHOQOL-BREF, Functional of Skindex-16, and Social/Professional of HRQ-Melasma, the greatest information was provided by Skindex-16, highlighting the sensitivity of this instrument to detect changes in the quality of life caused by melasma.

Melasma is a chronic dermatological disease that impacts significantly on psychological and emotional aspects affecting one’s quality of life. Furthermore, dermatological diseases that are visible are associated to higher psychiatric morbidities [36, 37]. Patients with facial Melasma frequently report feelings of frustration, shame, low self-esteem, anxiety and depression [38,39,40].


Finally, it is important to highlight that the lack of similar comparative studies on quality of life instruments made difficult for us to compare and discuss our key findings. However, it also showed that further studies are needed in this area. Another potential limitation of the present study relates to the fact that the questionnaire was applied only once and, therefore, not allowing us to perform both responsiveness and temporal stability analyses.


Overall, the three quality of life instruments tested showed good psychometric performance with satisfactory internal consistency values. However, only the dermatological specific instruments showed a strong correlation between domains that assess the social, emotional, and functional aspects of QOL, highlighting the sensitivity of both to identify impairments in other domains of quality of life, besides the physical one. Furthermore, Skindex-16 and HRQ-Melasma showed superior information on items in most domains.

Availability of data and materials

The data that support the findings of this study are stored in a research server at the São Paulo State University (UNESP) medical school, Botucatu, Brazil. An anonymous dataset in Excel format can be made available. For data access requests, please contact the Chair of the Ethics Committee of the Faculty of Medicine of Botucatu, Dr Silvana Andreia Molina Lima, e-mail:, Botucatu, Sao Paulo, ZIP Code: 18618-000, Brazil, Telephone no. +55 14 38801608.


  1. Pollo CF, Miot LDB, Meneguin S, Miot HA. Development and validation of a multidimensional questionnaire for evaluating quality of life in melasma (HRQ-melasma). An Bras Dermatol. 2018;93(3):391–6.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Tamega AD, Miot LD, Bonfietti C, Gige TC, Marques ME, Miot HA. Clinical patterns and epidemiological characteristics of facial melasma in Brazilian women. J Eur Acad Dermatol Venereol. 2013;27(2):151–6.

    Article  Google Scholar 

  3. Uyanikoglu H, Aksoy M. Quality of life in patients with melasma in Turkish women. Dermatol Rep. 2017;9(2):7340.

    Article  Google Scholar 

  4. Miot LDB, Miot HA, Silva MG, Marques MEA. Fisiopatologia do melasma. An Bras Dermatol. 2009;84(6):623–35.

    Article  PubMed  Google Scholar 

  5. Sheth VM, Pandya AG. Melasma: a comprehensive update: part I. J Am Acad Dermatol. 2011;65(4):689–97.

    Article  PubMed  Google Scholar 

  6. Cestari TF, Hexsel D, Viegas ML, Azulay L, Hassun K, Almeida ART, et al. Validation of a melasma quality of life questionnaire for Brazilian Portuguese language: the MelasQoL-BP study and improvement of QoL of melasma patients after triple combination therapy. Br J Dermatol. 2006;156(Suppl 1):13–20.

    Article  PubMed  Google Scholar 

  7. Videira IF, Moura DF, Magina S. Mechanisms regulating melanogenesis*. An Bras Dermatol. 2013;88(1):76–83.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Maranzatto CFP, Miot HA, Miot LDB, Meneguin S. Psychometrican analysis and dimensional structure of the Brazilian version of melasma quality of life scale (MELASQoL-BP). An Bras Dermatol. 2016;91(4):422–8.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Purim KSM, Avelar MF. Fotoproteção, melasma e qualidade de vida em gestantes. Rev Bras Ginecol Obstet. 2012;34(5):228–34.

    Article  PubMed  Google Scholar 

  10. Handel AC, Miot LDB, Miot HA. Melasma: a clinical and epidemiological review. An Bras Dermatol. 2014;89(5):771–82.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Taborda M-LVV, Weber MB, Freitas ES. Avaliação da prevalência de sofrimento psíquico em pacientes com dermatoses do espectro dos transtornos psicocutâneos. An Bras Dermatol. 2005;80(4):351–4.

    Article  Google Scholar 

  12. Deshpande SS, Khatu SS, Pardeshi GS, Gokhale NR. Cross-sectional study of psychiatric morbidity in patients with melasma. Indian J Psychiatry. 2018;60(3):324–8.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Dominguez AR, Balkrishnan R, Ellzey AR, Pandya AG. Melasma in Latina patients: cross-cultural adaptation and validation of a quality-of-life questionnaire in Spanish language. J Am Acad Dermatol. 2006;55(1):59–66.

    Article  PubMed  Google Scholar 

  14. WHOQOL Group. The World Health Organization Quality of Life Assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med. 1995;41(10):1403–9.

    Article  Google Scholar 

  15. Pollo CF, Miot LDB, Meneguin S, Miot HA. Factors associated with quality of life in facial melasma: a cross-sectional study. Int J Cosmet Sci. 2018;40(3):313-16.

  16. Minayo MC, Hartz ZM, Buss PM. Qualidade de vida e saúde: um debate necessário. Ciênc saúde coletiva. 2000;5(1):7–18.

    Article  Google Scholar 

  17. Gomes JR, AA, Hamann EM, Gutierrez MMU. Application of the WHOQOL-BREF in a community segment as a subsidy for health promotion actions. Rev bras epidemiol. junho de. 2014;17(2):495–516.

    Article  Google Scholar 

  18. Cárcano CBM, de Oliveira CZ, Paiva BSR, Paiva CE. The Brazilian version of Skindex-16 is a valid and reliable instrument to assess the health-related quality of life of patients with skin diseases. Toland AE, organizador. PLoS One. 2018;13(3):e0194492.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Aguiar CCT, Vieira APGF, Carvalho AF, Montenegro-Junior RM. Instrumentos de avaliação de qualidade de vida relacionada à saúde no diabetes melito. Arq Bras Endocrinol Metab. 2008;52(6):931–9.

    Article  Google Scholar 

  20. Alexandre NMC, Gallasch CH, Lima MHM, Rodrigues RCM. A confiabilidade no desenvolvimento e avaliação de instrumentos de medida na área da saúde. Rev Eletr Enf. 2013;15(3):800–7.

    Article  Google Scholar 

  21. Mokkink LB, Prinsen CAC, Bouter LM, HCW V, Terwee CB. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and how to select an outcome measurement instrument. Braz J Phys Ther. 2016;20(2):105–13.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Keszei AP, Novak M, Streiner DL. Introduction to health measurement scales. J Psychosom Res. 2010;68(4):319–23.

    Article  PubMed  Google Scholar 

  23. Fleck MP, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, et al. Aplicação da versão em português do instrumento abreviado de avaliação da qualidade de vida “WHOQOL-bref”. Rev Saúde Pública. 2000;34(2):178–83.

    Article  CAS  PubMed  Google Scholar 

  24. Taber KS. The Use of Cronbach’s Alpha When Developing and Reporting Research Instruments in Science Education. Res Sci Educ. 2018;48:1273–96.

    Article  Google Scholar 

  25. Miot HA. Correlation analysis in clinical and experimental studies. J vasc bras. 2018;17(4):275–9.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Baker FB. The basics of item response theory. 2nd ed. College Park: ERIC Clearinghouse on Assessment and Evaluation; 2001. p. 176.

    Google Scholar 

  27. Nunes CHSS, Primi R. Impacto do tamanho da amostra na calibração de itens e estimativa de escores por teoria de resposta ao item. Aval psicol. 2021;4(2):141–53.

    Google Scholar 

  28. Malta M, Cardoso LO, Bastos FI, Magnanini MMF, CMFP S. Iniciativa STROBE: subsídios para a comunicação de estudos observacionais. Rev Saúde Pública. junho de. 2010;44(3):559–65.

    Article  Google Scholar 

  29. Kang WH, Yoon KH, Lee E-S, Kim J, Lee KB, Yim H, et al. Melasma: histopathological characteristics in 56 Korean patients. Br J Dermatol. 2002;146(2):228–37.

    Article  CAS  PubMed  Google Scholar 

  30. Polit DF, Yang F. Measurement and the measurement of change: a primer for the health professions. Philadelphia: Wolters Kluwer; 2016. p. 350.

    Google Scholar 

  31. Polit DF. Assessing measurement in health: Beyond reliability and validity. Int J Nurs Stud. 2015;52(11):1746–53.

    Article  PubMed  Google Scholar 

  32. Mokkink LB, Terwee CB, Knol DL, Stratford PW, Alonso J, Patrick DL, et al. The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: A clarification of its content. BMC Med Res Methodol. 2010;10(1):22.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Castro SM, Trentini C, Riboldi J. Teoria da resposta ao item aplicada ao Inventário de Depressão Beck. Rev bras epidemiol. 2010;13(3):487–501.

    Article  PubMed  Google Scholar 

  34. Couto G, Primi R. Teoria de resposta ao item (TRI): conceitos elementares dos modelos para itens dicotômicos. Boletim de Psicologia. 2011;IXI(134):001–15.

    Google Scholar 

  35. Urasaki MBM, Mandelbaum MHSA, Gonçalves R. Impactos Psicossociais associados às manchas gravídicas. Cogitare Enferm. 2013;18(4):655–62.

    Article  Google Scholar 

  36. Jusuf NK, Putra IB, Mahdalena M. Is There a Correlation between Severity of Melasma and Quality of Life? Open Access Maced J Med Sci. 2019;7(16):2615–8.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Picardi DA, Cristina RA. Increased Psychiatric Morbidity in Female Outpatients with Skin Lesions on Visible Parts of the Body. Acta Dermato-Venereologica. 2001;81(6):410–4.

    Article  CAS  PubMed  Google Scholar 

  38. Ikino JK, Nunes DH, VPM S, Fröde TS, Sens MM. Melasma and assessment of the quality of life in Brazilian women. An Bras Dermatol. 2015;90(2):196–200.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Grimes PE, Ijaz S, Nashawati R, Kwak D. New oral and topical approaches for the treatment of melasma. Int J Women’s Dermatol. 2019;5(1):30–6.

    Article  CAS  Google Scholar 

  40. Espósito MCC, Espósito ACC, Jorge MFS, D’Elia MPB, Miot HA. Depression, anxiety, and self-esteem in women with facial melasma: an Internet-based survey in Brazil. Int J Dermatol. 2021;60(9):e346–7

    Article  PubMed  Google Scholar 

  41. The Whoqol Group. Development of the World Health Organization WHOQOL-BREF Quality of Life Assessment. Psychol Med. 1998;28(3):551–8.

    Article  Google Scholar 

Download references


Not applicable


Dr Cesar de Oliveira is supported by the Economic and Social Research Council (ESRC) (grant: ES/T008822/11) and Silmara Meneguin is supported by the Fundação de Amparo à Pesquisa do Estado de São Paulo (grant: 2017/17250-0).

Author information

Authors and Affiliations



Study design and concept: SM, HAM and IBM. Acquisition, analysis, and interpretation of data: SM, HAM, IBM and CFP. Drafting of the manuscript: SM, CFP and IBM. Critical revision of the manuscript for important intellectual content: CO. The author(s) read and approved the final manuscript. CO, CFP and SM. Approval of the final version: SM and CO.

Corresponding author

Correspondence to Silmara Meneguin.

Ethics declarations

Ethics approval and consent to participate

The project was approved by the ethics committee of the São Paulo State University (UNESP), Sao Paulo (protocol number 2.392.601). All of the patients were informed of the benefits and risks related to the study and provided their written informed consent for the study and for the publication of results. We confirm that all methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare that this research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Meneguin, S., Mourão, I.B., Pollo, C.F. et al. Comparison of generic and specific instruments to assess the quality of life in patients with melasma. BMC Med Res Methodol 22, 117 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: