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Dermatology > PHOTO-RELATED DISEASES
Ephelides (Freckles)
Article Last Updated: Jan 12, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 9  
Author: Shane G Silver, MD, Staff Physician, Assistant professor, Department of Dermatology, University of Manitoba, Canada
Coauthor(s):
Lorne Hurst, MD, Consulting Staff, Department of Dermatology, Winnipeg Health Sciences Centre
Editors: Sungnack Lee, MD, Vice President of Medical Affairs, Professor, Department of Dermatology, Ajou University School of Medicine, Korea; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Christen M Mowad, MD, Assistant Professor, Department of Dermatology, Geisinger Medical Center; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
Author and Editor Disclosure
Synonyms and related keywords:
freckles, xeroderma pigmentosum
Background
Ephelides are tanned macules found on the skin. They are usually multiple in number. With sun exposure, they become more apparent; therefore, in the winter months, they are often imperceptible. Although ephelides are predominantly benign, they may be seen in association with systemic disease.
Pathophysiology
Individuals who are genetically susceptible may have somatic mutations in epidermal melanocytes that promote increased melanogenesis. Melanocytes are not increased in number, and they may even be decreased in number. With UV-A and UV-B exposure, the dopa reaction is increased, leading to the production of larger melanosomes, which produce the clinical picture.
Frequency
International
In the United States and worldwide, ephelides may be found in varying degrees in most, if not all, individuals. They are more pronounced in individuals living in temperate climates.
Mortality/Morbidity
- Ephelides have an impact on cosmesis and are not associated with increased mortality.
- Mortality may be increased in diseases associated with ephelides, such as xeroderma pigmentosum.
Race
Ephelides are more common in fair-skinned and red- or blond-haired white persons than in individuals of other races.
Sex
Ephelides are distributed equally between the sexes.
Age
Commonly, ephelides first appear at age 2 years and increase in number into young adulthood. In older ages, the number usually decreases.
History
- Ephelides present during childhood as scattered areas of increased pigmentation, mainly limited to body regions above the waist.
- The macules are asymptomatic, more numerous on sun-exposed areas, and fade and become smaller in the winter.
Physical
- Simple ephelides are multiple, small, tanned macules, ranging from 1-5 mm in diameter, with uniform pigmentation.
- They are most commonly found on sun-exposed areas, such as the nose, the cheeks, the shoulders, and the upper part of the back.
- The macules may be discrete or confluent.
- Sunburn freckles present similarly to that of simple freckles, but they are darker, have irregular borders, and may be as large as a few centimeters.
Causes
- Genetic: Freckles tend to be inherited as an autosomal dominant trait. Ephelides are most common in individuals with fair skin and/or with blond or red hair.
- Xeroderma pigmentosum: Freckles are prominent and even dark in heterozygous carriers with this autosomal recessive disease. Excessive freckling in dark-haired individuals suggests the possibility of this disease.
- Environmental: In individuals who are susceptible, sunlight exposure to both UV-A and UV-B radiation induces freckles by stimulating melanocytes to produce melanin.
- Neurofibromatosis: Freckles can be found in the folded regions in individuals with this autosomal dominant condition.
Lentigo
Malignant Melanoma
Neurofibromatosis
Nevi, Melanocytic
Seborrheic Keratosis
Xeroderma Pigmentosum
Other Problems to be Considered
Café au lait spots
Lentigo maligna
Lab Studies
- Laboratory studies are not necessary.
Imaging Studies
- Imaging studies are not necessary.
Procedures
- Biopsy is rarely necessary, but it may be performed for a definitive diagnosis.
Histologic Findings
Histopathologically, the epidermis is unchanged. Specifically, the number of melanocytes is not increased. However, the melanosomes are larger than those in the surrounding skin.
Medical Care
Treatment is not necessary.
- If a patient wishes to alter the cosmetic appearance, then sun avoidance and makeup can be used.
- Sunscreens may be used to prevent enhancement of the freckling caused by sun exposure.
- If desired, chemical peels, cryotherapy, and laser treatment have all been attempted to make ephelides less pronounced.
Complications
- Ephelides may be cosmetically unappealing, but they are not associated with any complications. However, recent studies have shown that individuals with skin types susceptible to ephelides are at greater risk for developing skin cancers. This association is simply because ephelides and skin cancers are more common in people who are regularly exposed to the sun and have skin types I and II than in other people.
Prognosis
- The prognosis of ephelides is excellent.
Patient Education
- Patients should be reassured that ephelides are benign.
- Despite the benign nature of ephelides, patients should always be educated on the harmful effects of the sun.
- Patients should be informed to use sunscreens that protect against UV-A and UV-B radiation and to avoid sun exposure, especially between peak hours (10:00 am to 4:00 pm).
| Media file 1:
The arrow on the right is pointing to a sunburn freckle. The arrow on the left is pointing to a simple freckle. |
 |  View Full Size Image | |
Media type: Photo
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Ephelides (Freckles) excerpt Article Last Updated: Jan 12, 2007
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