Freckles

Freckles are harmless concentrations of melanin that cause dark spots on the skin.

• Freckles are flat small tan or light-brown spots on sun-exposed skin.
• Freckles are more common on the face of red-headed, poorly pigmented individuals.
• Common freckles themselves are quite harmless and rarely develop into skin cancer.
• Most freckles are produced by exposure to ultraviolet light and typically fade in the winter.
• Unusual-appearing freckles may become malignant skin cancer.
• Peculiar appearing or symptomatic colored or pigmented spots should be examined by your dermatologist.
• Treatments are available to help lighten or eliminate bothersome freckles.

Freckles are flat, beige, brown circular spots that typically are the size of the head of a metal nail. The spots are multiple and may develop on sun-exposed skin after repeated exposure to sunlight. These are particularly common in people with red hair and a fair complexion. They may appear on children as young as 1 or 2 years of age.

Most freckles are generally uniform in color but can vary somewhat in color -- they may be reddish, yellow, tan, light brown, brown, or black -- but they are basically slightly darker than the surrounding skin. They may become darker and more apparent after sun exposure and lighten in the winter months. Freckles are due to an increase in the amount of dark pigment called melanin and an increase in the total number of pigment-producing cells called melanocytes. The word freckle comes from the Middle English freken, which, in turn, came from the Old Norse freknur, meaning "freckled." (Some speakers of Old English and Old Norse must have had a tendency to develop freckles.)

Ephelides (singular: ephelis) is the Greek word and medical term for freckle. This term refers to 1 mm-2 mm flat spots that are tan, slightly reddish, or light brown and typically appear during the sunny months. They are most often found on people with light complexions, and in some families, they are a hereditary (genetic) trait. People with reddish hair and green eyes are more prone to these types of freckles. Sun avoidance and sun protection, including the regular use of sunscreen, help to suppress the appearance of the freckles.

Lentigines (singular: lentigo) comes from the Latin word for lentil and is the medical term for certain types of larger pigmented spots most commonly present at the site of previous sunburn and sun damage. Lentigines are often darker than the common freckle and do not usually fade in the winter. This kind of spot is referred to as lentigo simplex or solar lentigo. The number of melanocytes and melanosomes (cellular structures that contain melanin pigment) are normal in number and appearance. Although occasionally lentigines are part of a certain rare genetic syndromes, for the most part they are just isolated and unimportant spots.

"Liver spots" or "age spots" are common names for solar lentigines on the back of the hands. The term "liver spot" is actually a misnomer since these spots are not caused by liver problems or liver disease. While lentigines do tend to appear over time, they are not in themselves a sign of old age but a sign of sun exposure.

Moles are small, almost sightless mammals (a shrew relative) that tunnel beneath the ground and occasionally damage suburban lawns and golf courses. This term when used to describe something on the skin is very nonspecific. Most of the time it refers to a brown to black flat to slightly elevated bump. The type of cells of which the bump is composed distinguish the real nature of mole. For example, a mole composed of benign melanocytes is called a melanocytic nevus.

Frequently, elderly people may have raised, brown, crusty lesions called seborrheic keratoses in or around the same areas where lentigines are plentiful. Seborrheic keratoses are also benign (not malignant) growths of the skin. Some patients call these growths "barnacles" or "Rice Krispies." Although they are most often medium brown, they can differ in color ranging anywhere from light tan to black. They occur in different sizes, too, ranging anywhere from a fraction of an inch (or centimeter) to an inch (2.5 cm) in diameter. Typically, these growths are around the size of a pencil eraser or slightly larger. Some lesions begin as a flat, brown spot, indistinguishable from a lentigo. Then they gradually thicken, forming the waxy stuck-on appearance of seborrheic keratoses. They look like they have either been pasted on the skin or may look like a dab of melted brown candle wax that dropped on the skin. Seborrheic keratoses may occur in the same areas as freckles. Seborrheic keratoses are also more common in areas of sun exposure, but they may also occur in sun-protected areas. When they first appear, the growths usually begin one at a time as small rough bumps. Eventually, they may thicken and develop a rough, warty surface.

Seborrheic keratoses are quite common especially after age 40. Almost everybody may eventually develop at least a few seborrheic keratoses during their lifetime. They are sometimes referred to as the "barnacles of old age."

Freckles are thought to develop as a result of a combination of genetic predisposition (inheritance) and sun exposure. The sun and fluorescent tanning lights both emit ultraviolet (UV) rays, which when absorbed by the skin enhances the production of melanin pigment by cutaneous melanocytes. People with blond or red hair, light-colored eyes, and fair skin are especially susceptible to the damaging effect of UV rays and likely to develop freckles. A freckle is essentially nothing more than an unusually heavy deposit of melanin at one spot in the skin.

Heredity or more accurately skin color is a very important factor in the susceptibility to form freckles. The tendency to freckles is inherited by individuals with fair skin and/or with blond or red hair. Very darkly pigmented individuals are unlikely to develop freckles.

Research in twin siblings, including pairs of identical twins and pairs of fraternal (nonidentical) twins, have found a striking similarity in the total number of freckles found on each pair of identical twins. Such similarities were considerably less common in fraternal twins. These studies strongly suggest that the occurrence of freckles is influenced by genetic factors. A number of genes have been associated with freckling: MC1R, IRF4. ASIP, TYR, and BNC2.

True freckles almost never occur on covered skin and pose essentially no health risk at all. They are all absolutely harmless. They are not cancerous and generally do not become cancerous. A rare skin finding called axillary freckling (freckles in the armpit) is occasionally seen in a rare inherited disease called neurofibromatosis. These freckles are quite different in appearance from the common variety in both their appearance and distribution.

• Hutchinson's freckle is a special type of skin cancer called a lentigo maligna melanoma. This is an uncommon superficial skin cancer that generally occurs on the faces of older adults who have a history of considerable sun exposure. Over the course of months to years, this condition may, if untreated, develop into a more aggressive malignant melanoma. A simple in-office test called a skin biopsy can help diagnose lentigo maligna.
• Melanoma: This very dangerous form of skin cancer may appear even in young people and on parts of the body that are sun-exposed, as well as those that are protected. While the exact cause of melanoma is not entirely known, ultraviolet rays are known to play a part. Melanomas can arise from a previously normal mole (melanocytic nevus) or pigmented spot that has been present many years or lifelong. Melanomas can also arise from completely normal skin without an apparent preexisting mole. In comparison with benign (noncancerous) freckles, melanomas tend to be larger, darker, and have more irregular color and shape variations. Most melanomas are actually flat and not raised as many people tend to incorrectly assume.

A warning

Anyone who has one or more uncertain pigmented spots should have their dermatologist evaluate them. Even verbal descriptions and photographs cannot convey enough information for satisfactory self-diagnosis. As always, it is better to be safe than sorry.

The American Academy of Dermatology recommends a full-body skin examination for adults as part of a routine annual health exam. It is important to have any new, changing, bleeding mole or growth examined by your physician or dermatologist as soon as possible. Skin cancers are curable if diagnosed and treated at an early stage.

Freckles are rarely treated. Several safe but expensive methods are available to help lighten or reduce the appearance of freckles. Frequently, multiple or a combination of treatments may be required for best results. Not everyone's skin will improve with similar treatments, and freckles can often recur with repeated UV exposures.

1. Bleaching or fading creams: Products containing hydroquinone and kojic acid can be purchased with and without a prescription. Higher concentrations of hydroquinone (over 2%) require a prescription. These products can help lighten freckles if they are applied consistently over a period of months. Bleaching or fading creams are most effective in combination with sun avoidance and sun protection.
2. Retinoids: Sometimes used in conjunction with other bleaching creams, tretinoin (vitamin A acid, Retin-A), tazarotene (Tazorac), and adapalene (Differin) also may help lighten freckles when applied consistently over a period of several months.
3. Cryosurgery: A light freeze with liquid nitrogen in the physician's office can be used to treat some types of freckles. Not all spots respond to this form of therapy.
4. Laser treatment: Multiple types of lasers may help lighten and decrease the appearance of freckles safely and effectively. Like cryosurgery, this is a simple and safe procedure with a high success rate and a low risk of scarring or skin discoloration.
5. Photofacials or Intense Pulsed Light treatments are another method to lighten and remove freckles. This is not a true laser technique but an intense light source.
6. Chemical peels can also help lighten freckles and improve irregular pigmentation.

There are no home remedies that adequately treat freckles. A quick Internet search will reveal a whole host of treatments, most of which are composed of a variety of edible goodies. Makeup can be of great benefit in concealing freckles.

Some people like their freckles, while others may be more bothered by their appearance. The cosmetic improvement of the skin is a frequent request among people with freckles. On the other hand, freckles are desirable by some people who like the special character or uniqueness these give them.

Freckles can have their value. One is in poetry. For example, without freckles, Oliver Wendell Holmes (1809-1894), the American physician, professor, and man of letters, could not have written:

His home! the Western giant smiles,
And twirls the spotty globe to find it;
This little speck, the British Isles? 'Tis but a freckle, never mind it.

Since we cannot change our own genetic component of freckling, our main prevention measures are aimed at sun avoidance and sun-protection, including

1. use of sunscreens with SPF (sun protection factor) 50,
2. use of wide-brimmed hats (6 inches),
3. use of sun-protective clothing (shirts, long sleeves, long pants),
4. avoidance of the peak sun hours of 10 a.m. to 4 p.m.,
5. seeking shade and staying indoors.

Freckle prevention is more effective than freckle removal. Freckle-reduction treatments are more difficult and often not satisfactory. People with known hereditary tendencies of freckling should start sun protection early in childhood. Much of the sun and UV skin damage occurs often while children are under age 18.

Fair-skinned people who are more prone to freckling and sunburns are also generally more at risk for developing skin cancers. Freckles may be a warning sign of sensitive skin that is highly vulnerable to sunburn and to potential skin cancer.