Brown spots and freckles

Author: Hon A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand,1997.


What are freckles?

Freckles are small flat brown marks arising on the face and other sun exposed areas. They are most often seen in fair skinned people, especially those with red hair, but they are an inherited characteristic that sometimes affects darker skin types as well.

The medical term for this type of freckle is ephelis (plural ephelides). The colour is due to pigment accumulating in the skin cells (keratinocytes).

Skin pigment (melanin) is made by cells called melanocytes. They don't produce much melanin during the winter months, but produce more when exposed to the sun. The melanin is diffused into the surrounding skin cells, called keratinocytes. The colour of ephelides is due to localised accumulation of melanin in keratinocytes.

Ephelides are more prominent in summer but fade considerably or disappear in winter as the keratinocytes are replaced by new cells.

As the person ages this type of freckle generally become less noticeable. Apart from sun protection, no particular treatment is necessary.

Freckles

What are lentigines?

Lentigines are flat brown marks. The most common type, the solar lentigo, arises in middle age and also results from sun damage (age spots). These are most often found on the face and hands, and are larger and more defined than freckles. Lentigines tend to persist for long periods and don't disappear in the winter (though they may fade).  

Solar lentigines are common in those with fair skin but are also frequently seen in those who tan easily or have naturally dark skin.

When evaluating an atypical solar lentigo, is important to distinguish solar lentigo from melanoma in situ, especially subtypes lentigo maligna and lentiginous melanoma. The freckle may have arisen recently, is made up of more than one colour or has irregular borders. It is sometimes also difficult to tell a benign lentigo from a melanoma histologically, particular if it is atypical melanocytic hyperplasia. Such lesions should be completely removed by surgical excision, with pathological examination.

Lentigines

Other brown marks

If the brown marks are scaly, they may be actinic keratoses (sun damage) or seborrhoeic keratoses (senile warts). In this case there is a proliferation of keratinocytes. Facial pigmentation may also be due to melasma, a chronic pigmentatary disorder.

Other brown marks

Prevention of brown marks

Not all brown marks can be prevented. Careful sun protection will reduce the number of new solar lentigines. Staying out of the sun and using sun protective clothing is much more effective than sunscreens alone. Sunscreens must have high sun protection factor (SPF 50+), good broad spectrum cover against ultraviolet radiation (UVA), and should be applied liberally and frequently.

Treatment of brown marks

Brown marks may fade with careful sun protection, broad spectrum sunscreen applied daily for 9 months of the year. Regular applications of anti-aging or fading creams may also help. These may contain hydroquinone, or antioxidants such as:

However, brown marks may be removed more rapidly and effectively by chemical peels, cryotherapy or certain pigment lasers that target melanin in the skin. Multiple treatments may be necessary.

Suitable green-light devices include:

Suitable red light devices include:

Intense pulsed light has a similar effect. Carbon dioxide and Erbium:YAG lasers vaporise the surface skin thus removing the pigmented lesions. A fractional laser may also be effective.

Results are variable but sometimes very impressive with minimal risk of scarring.

With superficial resurfacing techniques, there is minimal discomfort and no down-time but several treatments are often necessary. Unfortunately the treatment occasionally makes the pigmentation worse. Continued careful sun protection is essential, because the pigmentation is likely to recur next summer.

Effect of treatment

Follow-up

If there is any doubt whether a brown mark may be a cancer, your doctor may choose to observe the lesion (e.g. with mole mapping or photography) or excise it for pathological examination.

 

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