Ephelides (freckles) are tanned macules found on the skin. Ephelides are usually multiple in number. Although ephelides are predominantly benign, they may be seen in association with systemic disease.[1] Ephelides are associated with fair skin and red or blonde hair. In contrast to solar lentigines, ephelides are not strongly associated with age.[2] Note the image below.
 View Image | Numerous ephelides on a fair-skinned, red-haired child. Images courtesy of Ronald Grimwood, MD. |
Individuals who are genetically susceptible to ephelides 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.[3]
Worldwide, ephelides may be found in varying degrees in most, if not all, individuals. Ephelides are more pronounced in individuals living in temperate climates.
Ephelides have an impact on cosmesis but are not associated with increased mortality. Mortality may be increased in diseases associated with ephelides, such as xeroderma pigmentosum.
Ephelides are more common in fair-skinned and red- or blond-haired white persons than in individuals of other races.[4]
Ephelides are distributed equally between the sexes.
Commonly, ephelides first appear at age 2 years and increase in number into young adulthood. In older ages, the number usually decreases.
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.
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.[5]
Causes are as follows:
Biopsy is rarely necessary, but it may be performed for a definitive diagnosis of ephelides.
Histopathologically in ephelides, the epidermis is unchanged. Specifically, the number of melanocytes is not increased. However, the melanosomes are larger than those in the surrounding skin. Cellular atypia of melanocytes have been noticed in some freckles.[5]
In contrast, solar lentigines have an increased number of melanocytes in the basal cell layer.
Treatment is not necessary for ephelides (freckles). 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. In one study of 48 patients, 71% had at least 50% improvement in pigmentation with an intense pulsed light source.[11] Another study compared Q-switched alexandrite laser and intense pulsed light for the treatment of freckles and lentigines in Asian patients. The Q-switched alexandrite laser was found to be superior to intense pulsed light for freckle treatment.[12, 13]
Ephelides (freckles) may be cosmetically unappealing, but they are not associated with any complications. However, studies have shown that individuals with skin types susceptible to ephelides are at greater risk for developing both melanoma and nonmelanoma skin cancer.[14] This association is likely 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.
Numerous ephelides on a fair-skinned, red-haired child. Images courtesy of Ronald Grimwood, MD.
Numerous ephelides on a fair-skinned, red-haired child. Images courtesy of Ronald Grimwood, MD.
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