Letters to the Editor

7. Garner MF, Backhouse JL, Daskalopoulos G, Walsh JL.

Table 1: Patients diagnosed with syphilis
The Treponema pallidum haemagglutination (TPHA) test
Year Patients having syphilis Total % of total in biological false positive and leprosy sera. J Clin Pathol
1973;26:258-60.
Male Female Total STI cases 8. Cole MJ, Perry KR, Parry JV. Comparative evaluation of 15
2003 7 6 13 260 5 serological assays for the detection of syphilis infection. Eur J
2004 6 7 13 234 5.6 Clin Microbiol Infect Dis 2007;26:705-13.
9. Ray K, Bala M, Gupta SM, Khunger N, Puri P, Muralidhar S,
2005 7 3 10 245 4.1
et al. Changing trends in sexually transmitted infections
2006 8 7 15 201 7.5 at a Regional STD Centre in north India. Indian J Med Res
2007 6 2 8 179 4.5 2006;124:559-68.
10. Sanchez M. Syphilis. In: Wolff K, Goldsmith LA, Katz SI,
2008 6 3 9 231 3.9
Gilchrest BA, Paller AS, Leffel DJ, Editors. Dermatology in
2009 7 3 10 209 4.8 General Medicine. 7th ed. New York: McGraw- Hill 2008.
2010 10 1 11 154 7.1 p. 1955-77.
2011 8 4 12 167 7.2 11. Siddappa K, Ravindra K. Syphilis and Nonvenereal
Treponematoses. In: Valia RG, Valia AR, Editors. IADVL
2012 9 3 12 127 9.4 Textbook of Dermatology. 3rd ed. Mumbai: Bhalani Publishing
Total 74 39 113 2007 5.6 House; 2008. p. 1803-47.
STI: Sexually transmitted infection

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‘Prenatal syphilis’ is used to denote syphilis transmitted
Quick Response Code: Website:
to the fetus in utero by the infected mother and is www.ijdvl.com
considered to be a better terminology than congenital
DOI:
syphilis.[10,11]
10.4103/0378-6323.152290

We suggest that all STI patients should be offered
screening for syphilis with both VDRL and TPHA tests
so as to detect all late latent syphilis cases.
Sarita Sasidharanpillai, Valiaveetil Bindu,
Najeeba Riyaz, Pentam V. Beegum Sherjeena,
Saleem Rahima, Nirmal Chandrasekhar
Department of Dermatology and Venereology, Govt. Medical College,
Kozhikode, Kerala, India
Address for correspondence: Dr. Sarita Sasidharanpillai,
‘Rohini’, Girish Nagar, Nallalom PO, Kozhikode - 673 027,
Kerala, India.
E-mail: saritasclt@gmail.com
REFERENCES
1. Saidharanpillai S, Bindu V, Riyaz N, Beegum Sherjeena PV,
Rahima S, Chandrasekhar N. Syphilis among sexually
transmitted infections clinic attendees in a tertiary care
institution: A retrospective data analysis. Indian J Dermatol
Venereol Leprol 2014;80:161-2.
2. World Health Organization. Treponemal infections. Technical
reports series 674. Geneva: WHO; 1982.
3. Thakar YS, Chande C, Mahalley AD, Saoji AM. Seroprevalence of
syphilis by TPHA test. Indian J Pathol Microbiol 1996;39:135-8.
4. Bala M, Toor A, Malhotra M, Kakran M, Murlidhar S,
Ramesh V. Evaluation of the usefulness of Treponema pallidum
haemagglutination test in the diagnosis of syphilis in weak
reactive Venereal Disease Research Laboratory sera. Indian J
Sex Transm Dis 2012;33:102-6.
5. Archana BR, Prasad SR, Beena PM, Okade R. Making serological
diagnosis of syphilis more accurate. Indian Sex J Transm Dis
2014;35:70-1.
6. Centers for Disease Control and Prevention. Discordant Results
from Reverse Sequence Syphilis Screening — Five Laboratories,
United States, 2006–2010 MMWR MMWR Morb Mortal Wkly
Rep 2011;60:133-7.
PMID:
*****
The pH of skin cleansers for acne
Sir,
The effectiveness of cleansers is influenced by many
factors including the pH, nature, and the composition
of cleansers, especially surfactants. Our purpose was
to study the pH of commonly available cleansers in the
market for acne patients. The pH values of cleansing
bars, liquid cleansers, foams, and scrubs promoted
for acne patients were measured and compared with
cleansers that are marketed for use on oily skin, baby
skin, or sensitive skin (mild cleansers), as well as
with general cleansers and antiseptic cleansers. All
cleansers were dissolved to make a 5% solution (weight
by volume) as per the actual usage condition. The
pH was determined using a pH meter (Thermo Scien
Oion 2 Star, Thermo Fisher Scientific Inc., Beverly,
MA, USA) and pH indicator strips (pH 0–14 Universal
indicator strips; Merck, Darmstadt, Germany). Each
sample was measured twice to obtain an average pH
value.
The average pH values of cleansers are shown in
Tables 1–3. All acne cleansing bars had an alkaline
pH (pH 9.0–10.4), as was found in all other types of
cleansing bars, except for syndet bar, which gave a

Indian Journal of Dermatology, Venereology, and Leprology | March-April 2015 | Vol 81 | Issue 2 181
Letters to the Editor

neutral pH, and a cleansing bar for oily skin, which dressings.[1] Since the skin has an acidic pH, facial
had an acidic pH [Table 1]. The pH of liquid cleansers washing with soap can increase the pH level by 1.5–
for acne (n = 9) ranged between 3.0 and 8.0 (5 = acidic 2.0. The increase in pH of cleansers potentiates skin
pH, 3 = neutral pH, 1 = alkaline pH). Most of the other dryness and tightness and also enhances the risk of
types of liquid cleansers had neutral pH, except for cutaneous reactions. On the other hand, lowering the
antiseptic cleansers [Table 2]. pH is supposed to benefit antibacterial effect. Goodman
suggested that acne cleansers should be “soap-free,”
Table 3 shows the pH of foams and scrubs. Most “acidic” or “pH-balanced,” and free of abrasives or
foams available in the market had an alkaline pH. alcohols, and should also have high rinsibility.[2] It
The pH values of two acne foams were found to be has been proposed that in order to control acne, the
similar to that of normal healthy skin (pH 5.4–5.9). optimal value of skin pH should be 5.4–6.0 for females
Three acne scrubs were found to have an acidic and 5.5 for males.[3]
pH and one each had a neutral and an alkaline
pH [Table 3]. In our study, it was found that all acne cleansing bars,
in spite of various compositions, had an alkaline pH.
Alteration of the skin pH is proposed to be one of the Korting et al. compared the efficacy of an alkaline
important factors for acne development, which may be soap bar with an acidic syndet in 120 acne patients
due to the change of skin resident microflora. The skin (a randomized controlled study) and found that after
pH can be influenced by many factors, i.e. genetics, 3 months, the number of acne lesions and cutaneous
age, gender, anatomical sites, skin moisture, sweat, irritation were lower in patients using an acidic
sebum, soaps, detergents, cosmetics, and occlusive syndet.[4]

Table 1: Comparison of the pH values of acne cleansing bars and other cleansing bars
Type of Sample Composition and properties Average Average
cleansers pH by pH pH by
Chemical Mechanical exfoliant Antibacterial Oil
indicator pH meter
exfoliant (scrub) control
strips
Polyethylene

Triclocarban
Ground fruit

Niacinamide
magnesium
Lactic acid

Aluminum/

Zinc salts
Triclosan
hydroxyl

peroxide
Salicylic

Tea tree
Benzoyl

extracts
beads

Sulfur
Alpha

oxide
acids

acid

Soy
pits

Acne 1 9 10.0 10.24

cleansing 2 9 9 10.0 9.95
bars
3 9 9.5 9.75
4 9 9 10.0 10.08
5 9 10.0 10.36
6 9 10.0 10.32
7 9 9.0 9.13
8 9 10.0 10.37
Cleansing 9 6.0 5.91
bars for 10 10.0 10.03
oily skin
Baby 11 10.0 10.17
cleansing 12 10.0 10.18
bars
Syndet 13 9 7.0 7.09
cleansing
bars
General 14 10.0 11.31
cleansing 15 10.5 10.58
bars
Antiseptic 16 9 9 10.0 10.25
cleansing 17 9 9.5 9.87
bars

182 Indian Journal of Dermatology, Venereology, and Leprology | March-April 2015 | Vol 81 | Issue 2
 Letters to the Editor

Table 2: Comparison of the pH of acne liquid cleansers and other liquid cleansers
Type of Sample Composition and properties Average Average
cleansers pH by pH pH by
Chemical exfoliant Mechanical exfoliant Antibacterial Oil
indicator pH meter
(scrub) control
strips

Polyethylene

Triclocarban
Ground fruit

Niacinamide
magnesium
Lactic acid

Aluminum/

Zinc salts
Triclosan
hydroxyl

peroxide
Salicylic

Tea tree
Benzoyl

extracts
beads

Sulfur
Alpha

oxide
acids

acid

Soy
pits
Acne 18 9 9 9 a 9 7.0 6.91
liquid 19 9 9 5.5 5.63
cleansers
20 9 9 7.0 6.80
21 9 9 4.5 4.20
22 9 7.0 6.90
23 9 a 6.0 6.11
24 9 3.0 3.0
25 9 9 6.0 5.84
26 9 8.0 7.99
Cleansers 27 9 7.0 7.12
for oily 28 6.0 6.22
skin
29 7.0 7.04
Baby 30 7.0 6.90
cleansers 31 7.0 7.38
Syndet 32 7.0 7.06
cleansers
General 33 7.0 6.91
liquid 34 9 7.0 6.98
cleansers
Antiseptic 35 9 8.5 8.94
cleansers 36 9 9.0 9.35
a
Zinc gluconate

In general, liquid cleansers have more acidic pH corneocyte desquamation. The proposed anti-acne
than those of cleansing bars since their compositions property of scrubs is that the abrasion may unroof closed
include amphoteric, anionic, non-ionic, and silicone comedones. However, a vigorous scrub can damage the
surfactants. They also contain emollients and skin surface. Therefore, scrub should not be used more
humectants which lower the pH of products.[5] In this than once a week and is not recommended for patients
study, liquid cleansers for acne were found to have a with sensitive skin. Sixty percent of the tested scrubs
lower pH (pH 3.0–8.0) than those of acne cleansing for acne patients in this study showed an acidic pH.
bars (pH 9.0–10.0).
In summary, the pH values of facial cleansers depend
Foams are triphasic liquids composed of oil, organic on their formulation and composition. The increase
solvents, and water. They are formulated with a in pH potentiates skin dryness and tightness and also
hydrocarbon propellant (either butane or propane), enhances the risk of cutaneous reactions. Apart from
and also contain various fatty acids and alkalis which pH, other properties should be considered in selecting
influence their wide range of pH.[5] In this study, except the proper cleansers for acne patients.[6]
for two brands, which had the pH of normal skin, all
the others had an alkaline pH. ACKNOWLEDGMENTS

Facial scrubs are mechanical exfoliants. They contain This study would have not been possible without the
small granules in a cleansing base for enhancing support of Assistant Professor Leena Chularojanamontri. We

Indian Journal of Dermatology, Venereology, and Leprology | March-April 2015 | Vol 81 | Issue 2 183
Letters to the Editor

Table 3: Comparison of the pH of acne cleansing foams and scrubs and other cleansing foams and scrubs
Type of Sample Composition and properties Average Average
cleansers pH by pH pH by
Chemical Mechanical exfoliant Antibacterial Oil
indicator pH meter
exfoliant (scrub) control
strips

Alpha hydroxy

Salicylic acid

Polyethylene

Triclocarban
Ground fruit

Niacinamide
magnesium
Lactic acid

Aluminum/

Zinc salts
Triclosan

peroxide

Tea tree
Benzoyl

extracts
beads

Sulfur
oxide
acids

Soy
pits
Acne 37 9 9 5.5 5.32
cleansing 38 9 9 a 7.0 7.13
foams
39 9 9 9 9 10.0 9.80
40 9 9 9 10.0 10.03
41 9 10.0 10.01
42 9 9 6.5 6.28
43 9 10.0 10.26
44 9 9 7.0 6.82
45 9 10.0 10.35
46 9 8.5 8.67
47 9 9 10.0 9.87
48 9 9 10.0 9.78
49 9 b 8.5 8.52
50 9 10.0 10.15
51 9 5.5 5.31
52 9 4.5 4.63
Cleansing 53 a 10.0 10.22
foams for 54 9 10.0 10.09
oily skin
General 55 9 10.0 10.22
cleansing 56 10.0 9.94
foams
Acne 57 9 9 9 4.5 4.38
cleansing 58 9 9 9 6.5 6.33
scrubs
59 9 9 10.5 10.59
60 9 9 9 7.0 7.13
61 9 9 4.5 4.52
General 62 9 9 7.5 7.54
cleansing 63 9 6.5 6.56
scrubs
64 9 10.0 10.36
a
Zinc gluconate; bzinc sulfate

would like to thank Dr. Kamolwan Pongparit for her support REFERENCES
in manuscript preparation.
1. Kim MK, Patel RA, Shinn AH, Choi SY, Byun HJ, Huh CH, et al.
Evaluation of gender difference in skin type and pH. J Dermatol
Nakaraj Pluetrattanabha, Kanokvalai Kulthanan, Sci 2006;41:153-6.
Piyavadee Nuchkull, Supenya Varothai 2. Goodman G. Cleansing and moisturizing in acne patients. Am J
Clin Dermatol 2009;10:1-6.
Department of Dermatology, Faculty of Medicine, Siriraj Hospital,
3. Youn SH, Choi CW, Choi JW, Youn SW. The skin surface
Mahidol University, Bangkok, Thailand
pH and its different influence on the development of acne
lesion according to gender and age. Skin Res Technol
Address for correspondence: Prof. Kanokvalai Kulthanan, 2013;19:131-6.
Department of Dermatology, Faculty of Medicine, 4. Korting HC, Ponce-Pöschl E, Klövekorn W, Schmötzer G,
Siriraj Hospital, Mahidol University, 2 Wanglang Road, Arens-Corell M, Braun-Falco O. The influence of the regular
Bangkoknoi, Bangkok 10700, Thailand. use of a soap or an acidic syndet bar on pre-acne. Infection
E-mail: kanokvalai.kul@mahidol.ac.th 1995;23:89-93.

184 Indian Journal of Dermatology, Venereology, and Leprology | March-April 2015 | Vol 81 | Issue 2

5. Kuehl BL, Fyfe KS, Shear NH. Cutaneous cleansers. Skin
Therapy Lett 2003;8:1-4.
6. Solomon BA, Shalita AR. Effects of detergents on acne. Clinics
in Dermatol 1996;14:95-9.
Access this article online
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DOI:
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PMID:
*****
A curious case of hourly attacks
of disabling episodic spontaneous
hypothermia with hyperhidrosis
Sir,
A 55-year-old female patient presented with
complaints of episodic generalized sweating for the
past 8 years. These episodes consisted of 5–10 min of
disabling hyperhidrosis occurring at a fixed interval
of 1 h, 24 times a day [Figure 1]. Each episode was
preceded by a characteristic aura of epigastric
discomfort. There was no history of any confusion,
abnormal behavior or movements, seizures, flushing,
palpitations, dizziness, or any other physical
symptoms during the episode. There was no seasonal
or diurnal variation and the episodes persisted even
during bathing and sleeping. The only relieving
factor was any febrile illness. There was no history of
shivering, chills, or rigors during or after the episode.
There was no past history of head trauma or spinal
injuries. Family history and treatment history were
not contributory.
The patient was admitted in Department of Neurology,
Maharana Bhupal Government Hospital, Udaipur
for a period of 15 days, during which we observed
hourly episodes of hyperhidrosis, and subsequent
hypothermia. The episodes were not associated with
any changes in sympathetic activity [Table 1].
General physical examination was unremarkable.
Routine hematological and biochemical investigations
were normal. Human immunodeficiency virus
(HIV) serology was nonreactive. Hormonal profile,
electrocardiogram, X-ray chest, and magnetic resonance
imaging (MRI) brain did not reveal any abnormality.
Indian Journal of Dermatology, Venereology, and Leprology | March-April 2015 | Vol 81 | Issue 2
Letters to the Editor
There were diffuse cerebral dysrrythmias during
the hyperventilation phase of electroencephalogram
(EEG).
A provisional diagnosis of episodic spontaneous
hypothermia with hyperhidrosis (ESHH) was made.
Propranolol and various antiepileptic drugs including
phenytoin, carbamazepine, and sodium valproate
were tried, without any response. There was transient
improvement with cyproheptadine and clonidine,
which was followed by relapse.
Episodic spontaneous hypothermia with
hyperhidrosis is described as spontaneous episodes
of hyperhidrosis associated with hypothermia in the
absence of shivering. Various endocrine, autonomic,
electrolyte and sleep disturbances have been
postulated, but the cause remains obscure. The first
clinical case was described by Hines and Bannick
in 1934 in a patient suffering from intermittent
attacks of sweating followed by chills and subnormal
temperature for 10 years.[1] The episodes occurred
during a 4- to 6-week period each year at 2 hourly
intervals. In 1969, Shapiro et al. described the first
two cases of spontaneous periodic hypothermia with
hyperhidrosis associated with agenesis of corpus
callosum.[2] Reverse Shapiro syndrome, characterized
by periodic hyperthermia instead of hypothermia
was also found to be associated with agenesis of
corpus callosum.[3] Rodrigues et al. found a consistent
abnormality in cerebral neurotransmitter levels in
patients with spontaneous periodic hypothermia
without corpus callosum agenesis.[4] Recently,
Tambasco et al. highlighted that among all the cases
reported in literature, agenesis of corpus callosum
was seen in only 40% of cases.[5]
Figure 1: Profuse hyperhidrosis over back
185
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