Ephelides (Freckles)



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.

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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:

Laboratory Studies

Laboratory studies are not necessary for ephelides (freckles).

Imaging Studies

Imaging studies are not necessary for ephelides.


Biopsy is rarely necessary, but it may be performed for a definitive diagnosis of ephelides.

Histologic Findings

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.

Medical Care

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.


The prognosis for ephelides is excellent.


Jessica M Scruggs, MD, Resident Physician, Department of Dermatology, Scott and White Memorial Hospital, Texas A&M Health Science Center College of Medicine

Disclosure: Nothing to disclose.


Katherine H Fiala, MD, Assistant Professor, Department of Dermatology, Scott and White Northside Clinic

Disclosure: Nothing to disclose.

Specialty Editors

Sungnack Lee, MD, Vice President of Medical Affairs, Professor, Department of Dermatology, Ajou University School of Medicine, Korea

Disclosure: Nothing to disclose.

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Disclosure: Nothing to disclose.

Christen M Mowad, MD, Associate Professor, Department of Dermatology, Geisinger Medical Center

Disclosure: Nothing to disclose.

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Ackerman Academy of Dermatopathology, New York

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Lorne Hurst, MD, and Shane G. Silver, MD, and previous Chief Editor, William D. James, MD, to the development and writing of this article.


  1. Azizi E, Lusky A, Kushelevsky AP, Schewach-Millet M. Skin type, hair color, and freckles are predictors of decreased minimal erythema ultraviolet radiation dose. J Am Acad Dermatol. Jul 1988;19(1 Pt 1):32-8. [View Abstract]
  2. Bastiaens M, Hoefnagel J, Westendorp R, Vermeer BJ, Bouwes Bavinck JN. Solar lentigines are strongly related to sun exposure in contrast to ephelides. Pigment Cell Res. Jun 2004;17(3):225-9. [View Abstract]
  3. Cockerell CJ, Johnson TM, Swanson NA. Melanocytic nevi. J Cutan Med Surg. 1996;2:1561-3.
  4. Hurwitz S. Clinical Pediatric Dermatology. 2nd ed. Philadelphia, Pa: WB Saunders; 1993:211-2.
  5. Rhodes AR, Albert LS, Barnhill RL, Weinstock MA. Sun-induced freckles in children and young adults. A correlation of clinical and histopathologic features. Cancer. Apr 1 1991;67(7):1990-2001. [View Abstract]
  6. Yang S, Xu SX, Xiao FL, et al. Prevalence and familial risk of ephelides in Han Chinese adolescents. Arch Dermatol Res. Feb 2008;300(2):87-90. [View Abstract]
  7. Bastiaens M, ter Huurne J, Gruis N, Bergman W, Westendorp R, Vermeer BJ. The melanocortin-1-receptor gene is the major freckle gene. Hum Mol Genet. Aug 1 2001;10(16):1701-8. [View Abstract]
  8. Hölzle E. Pigmented lesions as a sign of photodamage. Br J Dermatol. Sep 1992;127 Suppl 41:48-50. [View Abstract]
  9. McLean DI, Gallagher RP. "Sunburn" freckles, café-au-lait macules, and other pigmented lesions of schoolchildren: the Vancouver Mole Study. J Am Acad Dermatol. Apr 1995;32(4):565-70. [View Abstract]
  10. Crowe FW. Axillary freckling as a diagnostic aid in neurofibromatosis. Ann Intern Med. Dec 1964;61:1142-3. [View Abstract]
  11. Kawada A, Shiraishi H, Asai M, et al. Clinical improvement of solar lentigines and ephelides with an intense pulsed light source. Dermatol Surg. Jun 2002;28(6):504-8. [View Abstract]
  12. Wang CC, Sue YM, Yang CH, Chen CK. A comparison of Q-switched alexandrite laser and intense pulsed light for the treatment of freckles and lentigines in Asian persons: a randomized, physician-blinded, split-face comparative trial. J Am Acad Dermatol. May 2006;54(5):804-10. [View Abstract]
  13. Vejjabhinanta V, Elsaie ML, Patel SS, Patel A, Caperton C, Nouri K. Comparison of short-pulsed and long-pulsed 532 nm lasers in the removal of freckles. Lasers Med Sci. Nov 2010;25(6):901-6. [View Abstract]
  14. Bliss JM, Ford D, Swerdlow AJ, et al. Risk of cutaneous melanoma associated with pigmentation characteristics and freckling: systematic overview of 10 case-control studies. The International Melanoma Analysis Group (IMAGE). Int J Cancer. Aug 9 1995;62(4):367-76. [View Abstract]
  15. Lorincz Al. Disturbances of melanin pigmentation: circumscribed melanoses. Dermatology. 1985;2:1273-7.
  16. Nicholls EM. Genetic susceptibility and somatic mutation in the production of freckles, birthmarks and moles. Lancet. Jan 13 1968;1(7533):71-3. [View Abstract]
  17. Pavlotsky F, Azizi E, Gurvich R, et al. Prevalence of melanocytic nevi and freckles in young Israeli males. Correlation with melanoma incidence in Jewish migrants: demographic and host factors. Am J Epidemiol. Jul 1 1997;146(1):78-86. [View Abstract]
  18. Wilson PD, Kligman AM. Do freckles protect the skin from actinic damage?. Br J Dermatol. Jan 1982;106(1):27-32. [View Abstract]

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.