Most of us can identify freckles. They are small (usually less than 0.5 centimeters), harmless brown spots that show up on the face, neck, shoulders, chest, arms, and backs of hands. Fair-skinned people and people of Celtic origin with light or red hair and blue eyes often have freckles. Freckles develop due to a combination of genetics and sun exposure. Your skin contains cells called melanocytes, which manufacture the pigment melanin. After exposure to ultraviolet (UV) rays, the melanocytes accelerate production and deposit the pigment in one spot in the skin.1 The spots fade or disappear when you stay out of the sun but then reappear with sun exposure. That’s the key difference between these brown spots and others that occur on our skin. They are neither moles (nevi) nor skin cancers, because those don’t come and go but, rather, barely change or continue to grow.
How to Prevent Them (If Possible)
While the freckles themselves do not pose a health risk, people with a proclivity to freckles are also candidates for skin cancer. Therefore, those who easily develop freckles should avoid the sun and certainly tanning beds, and use a broad-spectrum sunscreen of at least SPF 30. The National Weather Service and the Environmental Protection Agency (EPA) developed a zip-code-based UV index to forecast the risk of excessive exposure to UV rays. You can access the index, which tells you how cautious you should be when outdoors in your area, on the EPA’s website: www.epa.gov/sunsafety/uv-index-1.
Freckles are generally harmless. However, if you don’t like your freckles for cosmetic reasons, try covering them up with makeup, or better yet, stay out of the sun, to minimize their appearance and decrease your risk for premature aging and skin cancer, too! There are treatment options to lighten many of your freckles and maybe even eliminate some of them, but in general, the results are temporary. Sunlight is the main instigator, so if you protect yourself from UV rays, you may be able to slow the return of your freckles, but don’t be surprised if they reappear. Embrace them! Many people consider freckles a sign of cuteness or youthfulness. Smile and be proud of your freckles!
- SKIN-LIGHTENING CREAMS, also known as bleaching creams, containing kojic acid and up to 2 percent of a depigmenting agent called hydroquinone can be purchased over the counter. You’ll have to get a prescription for products containing higher concentrations of hydroquinone. You must apply these creams consistently over several months to see lightening. The best results come by combining regular use with sun avoidance.
Dermatologists in the United States typically prescribe topical hydroquinone cream in higher strengths—usually 4 percent and sometimes as high as 8 percent or more—but this is not without some controversy: in 2006 the US Food and Drug Administration (FDA) proposed banning hydroquinone because studies testing the medication in rodents showed that it heightened the risk of cancer if administered to the animals in very high doses via a feeding tube. Keep in mind that the results of animal studies are not always replicated in humans. There remains no ban on the topical use of hydroquinone; in fact, no evidence of increased carcinogenic risk in human beings has ever been reported. But due to this history and information, some people fear using this product on their skin. Personally, I don’t know a dermatologist anywhere in the world who refuses to prescribe topical hydroquinone in the strengths we favor. However, hydroquinone needs to be prescribed responsibly—not because of any risk of cancer but rather the risk of developing a skin condition called ochronosis.
It is ironic, given that patients may use hydroquinone to lighten their skin, that long-term use of the agent in high concentrations may actually darken the skin, causing a blue-gray pigmentation. Ochronosis may or may not fade after the person discontinues hydroquinone. Because of this, many dermatologists will not prescribe it in strengths above 4 percent. But I have seen prescriptions as high as 16 percent written by other physicians. I advise caution with the use of such high strengths, especially for a long duration. You don’t want your skin to turn even darker when you’re just trying to lighten and brighten it a little!
- THE RETINOIDS TRETINOIN (RETIN-A), TAZAROTENE (TAZORAC), AND ADAPALENE (DIFFERIN) are often combined with topical skin-lightening creams to help lighten freckles over several months when applied regularly.
- IN CRYOSURGERY, LIQUID NITROGEN is applied lightly to the skin, essentially creating a superficial frostbite. Most freckles respond to this safe, simple procedure. Liquid nitrogen treatment can potentially leave a permanent white spot by inadvertently destroying the pigment-producing cells at the treatment site if treatment is too aggressive. Accordingly, your doctor may start slow and small to see how your skin responds.
- SEVERAL TYPES OF LASER TREATMENTS have demonstrated a high success rate in fading and removing freckles. These are safe procedures with a low risk of discoloration or scarring. Neodymium:YAG and alexandrite lasers, the most common ones used, release small bursts of a specific wavelength to destroy the colored pigment that the freckles absorb.
- INTENSE PULSED LIGHT (IPL) TREATMENTS also lighten and remove freckles successfully. The pulsed light device distributes a broad wavelength of light, and that energy is also absorbed by the pigment of the freckle, destroying it.
- CHEMICAL PEELS can provide great results in removing freckles. Peels cause the outermost layers of your skin, which contain much of the pigment that makes up a freckle, to desquamate, or peel off.
Healing Time/Results, or “What to Expect”
The aforementioned treatments are generally successful, but everyone’s skin is different, and results will vary. Oftentimes multiple treatments or a combination of treatments are required to achieve optimal results. Even if your freckles are removed completely, it’s important to know that the spots can reappear with repetitive UV exposure. Think of it as a maintenance treatment: you will need to return regularly—maybe on a yearly basis—for touch-up visits, depending on the number of freckles you have and the level of improvement you want.
What You Can Do at Home, Where Applicable
Wear your sunscreen daily and reapply it every two hours if you have been actively perspiring or have gotten wet. At home, daily bleaching creams also do not require a visit to the doctor.
Okay, I don’t want to freak you out, but what you may think is a freckle could be something dangerous, like a skin cancer. The $10 million question is: How do you know? Well, there is a simple way to remember the potential signs of melanoma, which we commonly call the ABCDEs of melanoma:
A stands for asymmetry. If you drew a line down the middle of a freckle, are the two sides near mirror images of each other? Or does the spot have an irregular shape, with the two parts looking very different? That’s a characteristic of melanoma.
B stands for border. Look for a jagged or otherwise irregular border.
C is for color. Does the color look mottled?
D is for diameter. Is the “freckle” larger than a green pea?
E is for evolution. Has it changed noticeably in size, shape, or color over a few weeks or months? Always see your doctor if you notice changes in your skin, including any of the ABCDEs of melanoma.
When to See a Doctor
Your dermatologist is trained to evaluate you for skin cancer. Make an appointment right away if you notice a freckle, mole, spot, or growth that is new, changing, irritating, bleeding, asymmetric, has irregular borders, is variably colored, or is otherwise bothering you. If you can’t see a dermatologist, consult your primary health care professional, and if necessary, they will refer you to a dermatologist.