Chapter 23: Ephelides

INTRODUCTION

Ephelides, more commonly known as freckles, are benign, small, well-demarcated, brown macules found on the sun-exposed skin of blond, light brown, and red-haired individuals. They present in early childhood and decrease in older age. They can be distinguished from lentigines in that they darken in times of high sun exposure and fade during periods of limited sun exposure.

EPIDEMIOLOGY

Incidence: very common, particularly in fair-skinned patients

Age: early childhood

Race: more common in Caucasians, but also seen in Asians

Sex: equal

Precipitating factors: individuals with light hair and complexion such as blonds and redheads

PATHOGENESIS

The brown pigmentation associated with ephelides results from increased production of melanin in sun-exposed areas of the skin.

PATHOLOGY

Keratinocytes display an increase in melanin especially in the basal layer, but there is no substantial increase in the number of melanocytes in ephelides.

PHYSICAL LESIONS

Ephelides are well-demarcated light brown to dark brown macules of several millimeters diameter that present in sun-exposed areas of the skin.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis includes other benign lesions such as lentigines and junctional nevi.

LABORATORY EXAMINATION

None.

COURSE

They present in early childhood. They darken in periods of high sun exposure and lighten during periods of limited sun exposure.

KEY CONSULTATIVE QUESTIONS

• Sun exposure.

MANAGEMENT

There is no medical indication to treat ephelides. The cosmetic appearance, however, may displease some individuals. Sun avoidance and sunscreens protect against darkening of ephelides. Bleaching creams, such as hydroquinone, and topical retinoids can produce lightening. Cryotherapy and laser treatment are also effective. Recurrence is frequent, particularly with sun exposure.

TREATMENTS

Topical Treatment

Topical bleaching creams may provide some lightening. Multiple formulations are available differing in their product contents and strengths.

• Hydroquinone (2–4%) creams have traditionally been employed.

  • – Twice daily application of the cream to the ephelides over 3 months is generally necessary to achieve significant, if not complete, improvement.

  • – Side effects include irritation, pruritus, peeling, and dryness of the treated areas.

  • – If erythema and irritation occur, exercise caution to avoid hyperpigmentation, especially in darker skin phototypes.

  • – Patients must discontinue the treatment if any lightening of nonlesional skin is observed.

  • – Bleaching creams are contraindicated in pregnant and lactating women.

  • – Prolonged treatment may produce skin discoloration known as pseudo-ochronosis.

• Retinoids

  • – Retinoids have been added in products such as Solage (2% mequinol and 0.01% tretinoin) and Triluma (0.01% fluocinolone ...