Monday, March 13, 2017

Freckles

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Freckles
Multiple Responses
1.
Freckles, sometimes called ephelides (singular ephelis), are clusters of concentrated melaninized cells which are most easily visible on people with a fair complexion. Freckles do not have an increased number of the melanin-producing cells melanocytes, but instead have melanocytes that overproduce melanin granules (melanosomes) changing the coloration of the outer skin cells called (keratinocytes). As such, freckles are different from lentigines and moles.

2.
Freckles
Freckles facts
  • Freckles are flat small tan or light-brown spots on sun-exposed skin.
  • Common freckles themselves are quite harmless and never develop intoskin cancer.
  • Most freckles are produced by exposure to ultraviolet light.
  • Unusual-appearing freckles may become malignant skin cancer.
  • Uncertain colored or pigmented spots should be examined by your dermatologist.
  • Treatments are available to help lighten or eliminate bothersome freckles.

What are freckles?
Freckles are flat, tanned circular spots that typically are the size of the head of a common nail. The spots are multiple and may develop on sun-exposed skin after repeated exposure to sunlight. These are particularly common in people of fair complexion on upper-body skin areas like the cheeks, nose, arms, and upper shoulders. They may appear on people as young as 1 or 2 years of age.

Most freckles are uniform in color. On different people, freckles may 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 are not due to 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 developing freckles.)

What types of freckles are there?
There are two basic types of freckles: simple freckles and sunburn freckles. Simple freckles are usually tan, round, and small -- about the size of a common construction nail head. Sunburn freckles are often darker, have irregular jagged borders, and may be larger than a pencil eraser. Sunburn freckles are more common on the upper back and shoulders where people frequently get their most severe sunburns.

Ephelides (singular: ephelis) is the Greek word and medical term for freckle. This term refers to 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 darker freckles and sunburn freckles. Lentigines tend to be darker than the common freckle and do not usually fade in the winter. This kind of spot is referred to as lentigo simplex. Although occasionally lentigines are part of a certain rare genetic syndrome, for the most part they are just isolated and unimportant spots.

What are "liver spots" or "age spots"?
"Liver spots" or "age spots" are the common names of the darker spots seen in adults, frequently 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.

Sometimes, older people who have these lentigo-type freckles also have raised, brown, crusty lesions called seborrheic keratoses in or around the same areas. 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 keratoses begin as a flat lentigo and gradually raise and thicken to form a seborrheic keratosis.

The telltale feature of seborrheic keratoses is their waxy, stuck-on, greasy look. 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."

How do freckles develop?
Freckles are thought to develop as a result of a combination of genetic tendency (inheritance) and sun exposure. Two people receiving the same sun exposure may not have an equal chance of developing freckles. Natural sunlight and artificial suntanning lights emit ultraviolet (UV) rays. After exposure to ultraviolet rays, the outer layer of the skin (the epidermis) thickens and the pigment-producing cells (the melanocytes) produces the pigment melanin at an increased rate. (This production of melanin may give some protection against future sun exposure.)

Of course, people differ a great deal in their reaction to sunlight. To take an extreme example, there is no pigmentation in the skin of an albino because of a defect in melanin metabolism. On the other hand, people with dark complexions are relatively less sensitive to sun exposure than fair-skinned people. However, people with dark skin are not entirely resistant to the effects of the sun, and they, too, can become sunburned with prolonged exposure. People with blond or red hair, light-colored eyes, and fair skin are especially susceptible to the damaging effect of UV rays.

Freckling is caused by the uneven distribution of the melanin pigment in the skin. A freckle is essentially nothing more than an unusually heavy deposit of melanin at one spot in the skin.

How important is heredity with freckles?
Heredity and skin type are very important factors for the tendency to develop freckles. Freckles tend to be inherited genetically and are most common in individuals with fair skin and/or with blond or red hair.

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. The variations in freckle counts appear to be due largely to heredity.

Ongoing research in a rare disease called xeroderma pigmentosum has also confirmed the genetic tendency of freckles. Excessive freckles in dark-haired individuals are quite common in this disease.

Further, freckles are also found in skin folds like the underarms in another uncommon genetic disease called neurofibromatosis.

What is the medical meaning of freckles?
True freckles pose essentially no health risk at all. They are all absolutely harmless. They are not cancerous and generally do not become cancerous.

Rare concerns about freckles may arise when they are associated with other diseases like xeroderma pigmentosum and neurofibromatosis or when they are confused with the following, more serious conditions:
  • Lentigo maligna ("malignant freckle"): 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 variety called lentigo maligna melanoma. There are, of course, many hundreds of ordinary facial freckles for every one that is potentially malignant. 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 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.
  • Basal cell carcinoma: This is the most common type of skin cancer. These are usually pearly, pink or reddish in color, and may bleed easily. Pigmented basal cell carcinoma is a type of basal cell that may be confused with a freckle or seborrheic keratosis because of its brown or dark color. A simple procedure called a skin biopsy can help diagnose this growth.

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.

How can freckles be prevented?
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.

What is the treatment for freckles?
Several safe 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.

What is the value of 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.

3.
Are freckles dangerous? Dermatologists answer this and more questions about the spots

Those pretty little spots that speckle skin might be common, but freckles remain a bit of a dermatological mystery to many — including even those who have them. We interviewed three top skin specialists to get the low-down on the subject for the height of freckle season.

So, what exactly are freckles?
“Freckles, also known as ephelides, are dark spots caused by the sun,” says Dr. Joshua Zeichner, Director of Cosmetic and Clinical Research in Dermatology at Mt. Sinai Hospital in New York City. “They get darker in the summertime, when the skin is exposed to the sun, and fade themselves in the winter time.”

Caused by the sun’s ultraviolet rays, the sun stimulates the skin’s pigment-forming cells to produce more melanin in the skin but, according to Dr. Howard Murad, “although [freckles] are usually triggered by the sun, they will only form in those who are genetically pre-disposed to them."

I was born with freckles. Right?
Contrary to popular belief, nobody is born with freckles, which typically don't pop up until adolescence. That said, "freckles often ‘run in the family,’ especially in those with fair skin and light hair,” says Jessica Wu, MD, a Los Angeles-based dermatologist and Assistant Clinical Professor of Dermatology at USC School of Medicine. “Those with fair skin and red or blond hair may inherit skin pigment cells that are more sensitive to UV rays, so they produce more melanin pigment in those spots.”

So how do I know if my “spots” are actually freckles or something else?
“Freckles are often confused with sun spots, A.K.A. lentigos,” says Zeichner. Typically freckles are found only on sun-exposed parts of the skin like the face, arms, legs, and few or none on their breasts or buttocks, “unless they’re nudists”, jokes Wu.

Are freckles dangerous?
The spots themselves are absolutely nothing to fear, but, cautions Murad, “those who are genetically pre-disposed to freckles are often fair skinned as well, which in turn makes them more susceptible to skin cancers.” Wu agrees: “I do warn my patients with freckles to be extra diligent about using sunscreen, especially in the areas that are freckle-y. These areas have had more exposure to UV rays."

Can you (safely) fade your freckles?
Freckles can be lightened with proper treatment, and new freckles often fade on their own. “To fade freckles topically, look for products with vitamin C, azelaic acid, ellagic acid, bear berry and licorice root, which can be used to suppress and gradually lighten epidermal hyperpigmentation,” tells Murad. “They may also respond to prescription ingredients such as Retin A or hydroquinone,” states Wu. “I often use an Intense Pulsed Light (IPL) laser to fade freckles. The procedure takes 20 minutes.”

Is it possible to stop freckles from forming?
As with many things in life, prevention is key. “Wear sunscreen every day as part of your regimen, like brushing your teeth. [SPF] can help prevent [the formation and] darkening of freckles, sun burn, skin cancers and wrinkles,” says Zeichner.

So what does it all mean?

Safe sun practice is important for everyone, but having freckles means you need to be extra careful, especially when making sure your skin is protected with a broad-spectrum SPF. “You have inherited a predisposition to freckles, and you are likely to get more of them — in addition to risk of skin cancer — if you don’t use sun protection,” warns Wu.

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