Freckles (ephelides and lentigines)

Heather Stephen and Dr. Haran Sivapalan
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What are Freckles (ephelides and lentigines)?

Freckles are harmless flat spots caused by exposure to ultraviolet light. They may be yellow, tan, brown or black and are particularly common in people with a fair complexion. Freckles are normally seen on the cheeks, nose, arms and shoulders and appear in children as young as one year old. Most are uniform in colour.

There are two types of freckles: ephelides and lentigines. Ephelides (singular = ephilis) or ‘true freckles’ are smaller spots that are more common in people with red hair and green eyes. They characteristically become darker after exposure to sun and tend to fade in winter.

Lentigines (singular = lentigo) are larger, flat, pigmentedYEs spots that occur in skin that has been exposed to the sun over many years. In contrast to ephelides or ‘true freckles’, they do not get darker after exposure to the sun and do not fade in winter. They are more common in older people.

ephelides-freckles-nose-conditions

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True freckles (ephelides) arise when there is an increase in a dark skin pigment called melanin, which forms after exposure to UV rays in the sun. Melanin is produced by a type of skin cell called melanocytes. UV light causes melanin to form in melanocytes and then diffuse into another type of skin cell – keratinocytes. The build up of melanin in keratinocytes gives freckles (ephelides) their darker colour. Genes play a large role in the development of ephelides and research has shown a striking similarity in the number of freckles amongst identical twins.

Lentigines are also caused by increased melanin production, usually following exposure to UV light from the sun. Studies of lentigines also show that affected areas of skin have an increased number of melanocytes. Genes contribute less to the development of lentigines, with exposure to sunlight being the biggest factor.

Ephelides (simple or true freckles) are usually tan, round and about the size of a nail head. These spots typically appear during summer and are most common among people with red hair and green eyes. Ephelides characteristically tend to get darker in summer and fade in the winter. They typically develop
in childhood but may disappear with age.

Lentigines are larger freckles that characteristically do not get darker in summer. The most common type are ‘solar lentigines’ that occur after long-term exposure to the sun. These have irregular borders, are larger than ephelides – often about the size of the circumference of a pencil, and they tend not to fade in the winter.Freckles, ephelides, lentigines Solar lentigines are more common in people over 50 and appear most often on the face and hands.

Many people over 40 who have lentigines also have brown, crusty lesions in the same area. These seborrhoeic keratoses are benign growths but should always be checked by a doctor as they can look very similar to melanoma.

Other conditions mistaken for freckles

  • Lentigo maligna (malignant freckle). This is a rare skin cancer which appears on older people who have consistently exposed their skin to the sun. It normally appears as a brown patch on the face which gradually gets larger and darker and it can also be crusty or bleed. This should be surgically removed as, left untreated this can progress to the dangerous skin cancer If worried you may have one of these freckles talk to your doctor who will be able to arrange a skin biopsy where a sample of skin tissue is removed and examined under a microscope to either rule out or confirm melanoma.
  • Melanomas can arise from moles or pigmented spots as well as skin where no moles are present. Cancer Research UK says people with lots of freckles have more chance of developing melanoma, along with people who are very fair skinned, have blonde or red hair or who burn in the sun. In contrast to a normal freckle, melanomas tend to be larger, darker with an irregular shape and they are often flat, rather than raised as many people think.
  • Basal cell carcinoma is the most common type of skin cancer. These growths are normally pearly, pink or red but pigmented basal cell carcinoma is darker and can be confused with a freckle. Diagnosis is by a skin biopsy.

Freckles can be identified by a simple examination of the skin. Further investigations are not required. A doctor may want a sample of the skin ( called a biopsy) to exclude the possibility of certain skin cancers.

Freckles are harmless and do not usually require any medical treatment. Some people may find freckles to be unsightly.

Freckle reduction is difficult and freckles often come back after repeated UV exposure. The main treatments for freckle reduction are skin lightening creams, laser treatment, cryotherapy and chemical peels.

These treatments can help to lighten freckles by reducing the amount of melanin in the skin but they can be expensive, carry serious side effects and results are not guaranteed so you should always speak to your GP before going ahead. Not all the treatments will be available on the NHS.

Skin-lightening creams

These powerful creams usually contain one or more of: hydroquinone (a skin bleaching agent), tretinoin (a retinoid substance related to Vitamin A) or steroid medication such as hydrocortisone.

Products with these ingredients may cause serious side effects (e.g. liver or kidney damage) if used incorrectly so should only be used under the supervision of your prescribing doctor. Treatment usually takes three or four months.

Skin-lightening creams may temporarily cause redness, burning or stinging when applied to the skin.

There are many alternative skin-lightening products that are available online and in shops without prescription. While they are unlikely to cause harm, there is no guarantee they will work.

It is also possible to buy skin-lightening products online, but some may contain mercury. They are banned throughout Europe because they have been shown to cause a wide range of serious problems from kidney damage and depression to scarring and psychosis. Before ordering any such creams be sure to check the ingredients.

A survey carried out by the British Skin Foundation found 16 per cent of dermatologists believe lightening creams are completely unsafe and 80 per cent feel they are only safe when prescribed by a dermatologist.

Laser skin lightening

Lasers work by removing the outer layer of skin or by damaging the cells that produce melanin. Results and the cost of treatment may vary widely and several sessions are often needed.

Before the procedure a test may be carried out on a small area of skin. If there are no problems you can have your first session a few weeks later.

You may experience a stinging or pricking sensation, so a local anaesthetic cream may be used to numb your skin before the session. A treatment session usually which lasts between 30 to 60 minutes.

Following the procedure, your skin is normally red and swollen for a few days and may be bruised or crusty for a week or two. It will be sensitive to the sun for up to six months so you will need to use sunscreen at all times

Serious complications of laser treatment are rare but can include: scarring, skin infection and darkening or lightening of parts of the skin.

Chemical Peels

Chemical peels involve brushing abrasive liquids onto the face to remove dead skin cells and stimulate the growth of new cells. There are three types of peel: superficial, medium and deep. The effects of a superficial or medium peel are temporary. A deep peel has long lasting effects but is much more expensive, painful and risky.

Possible risks include:

  • Darkening or lightening of the skin which can be permanent
  • Recurrent cold sores if you’ve had these before
  • Scarring or infection – although this is rare

If you have a superficial or medium peel the solution is only left on the skin for a few minutes. After a superficial peel the skin may feel tight. It may take some time for results to be seen and these may be minimal.

During a medium peel you may feel stinging. Afterwards your skin will go brown or red and could take up to six weeks to return to normal. Treatment will be required again in six to 12 months.

A deeper peel is left on the face for 30 minutes or more. When applied there may be a freezing sensation and oral pain relief may be prescribed to combat pain after the procedure.

During a deep peel your heart and blood pressure need to be monitored as the chemical used can be dangerous for the heart and kidneys.

Afterwards you will experience peeling and discomfort for a few days, swelling for up to two weeks and redness which can last up to three months. The treatment doesn’t normally need to be repeated.

Cryotherapy

Cryotherapy involves freezing the top layer of skin using liquid nitrogen or carbon dioxide. Freezing causes the pigmented cells to die and fall off. It is suitable for individual lentigines.

Cryotherapy can causes blistering, but this usually settles. The procedure also leaves a small scab, but skin usually completely heals over a period of weeks.

Reducing exposure to the sunlight can help reduce the development of further freckles. In order to protect yourself from the sun, you can:

  • Use sunscreens with a Sun Protection Factor of at least 50.
  • Wear wide brimmed sunhats and long sleeved shirts and trousers in the sun
  • Stay out of the sun between 10am and 4pm
  • When outside in summer always seek the shade
  • Make sure children are well protected against the sun as most UV damage occurs before the age of 18