Letters to the Editor 7.
Table 1: Patients diagnosed with syphilis Year
Patients having syphilis
Total
% of total
Male
Female
Total
STI cases
2003
7
6
13
260
5
2004
6
7
13
234
5.6
2005
7
3
10
245
4.1
2006
8
7
15
201
7.5
2007
6
2
8
179
4.5
2008
6
3
9
231
3.9
2009
7
3
10
209
4.8
2010
10
1
11
154
7.1
2011
8
4
12
167
7.2
2012
9
3
12
127
9.4
Total
74
39
113
2007
5.6
Garner MF, Backhouse JL, Daskalopoulos G, Walsh JL. The Treponema pallidum haemagglutination (TPHA) test in biological false positive and leprosy sera. J Clin Pathol 1973;26:258-60. 8. Cole MJ, Perry KR, Parry JV. Comparative evaluation of 15 serological assays for the detection of syphilis infection. Eur J Clin Microbiol Infect Dis 2007;26:705-13. 9. Ray K, Bala M, Gupta SM, Khunger N, Puri P, Muralidhar S, et al. Changing trends in sexually transmitted infections at a Regional STD Centre in north India. Indian J Med Res 2006;124:559-68. 10. Sanchez M. Syphilis. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, Editors. Dermatology in General Medicine. 7th ed. New York: McGraw- Hill 2008. p. 1955-77. 11. Siddappa K, Ravindra K. Syphilis and Nonvenereal Treponematoses. In: Valia RG, Valia AR, Editors. IADVL Textbook of Dermatology. 3rd ed. Mumbai: Bhalani Publishing House; 2008. p. 1803-47.
STI: Sexually transmitted infection
‘Prenatal syphilis’ is used to denote syphilis transmitted to the fetus in utero by the infected mother and is considered to be a better terminology than congenital syphilis.[10,11] 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: [email protected]
REFERENCES 1.
2. 3. 4.
5. 6.
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. World Health Organization. Treponemal infections. Technical reports series 674. Geneva: WHO; 1982. Thakar YS, Chande C, Mahalley AD, Saoji AM. Seroprevalence of syphilis by TPHA test. Indian J Pathol Microbiol 1996;39:135-8. 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. Archana BR, Prasad SR, Beena PM, Okade R. Making serological diagnosis of syphilis more accurate. Indian Sex J Transm Dis 2014;35:70-1. 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.
Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.152290 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 had an acidic pH [Table 1]. The pH of liquid cleansers for acne (n = 9) ranged between 3.0 and 8.0 (5 = acidic pH, 3 = neutral pH, 1 = alkaline pH). Most of the other types of liquid cleansers had neutral pH, except for antiseptic cleansers [Table 2]. Table 3 shows the pH of foams and scrubs. Most foams available in the market had an alkaline pH. The pH values of two acne foams were found to be similar to that of normal healthy skin (pH 5.4–5.9). Three acne scrubs were found to have an acidic pH and one each had a neutral and an alkaline pH [Table 3]. Alteration of the skin pH is proposed to be one of the important factors for acne development, which may be due to the change of skin resident microflora. The skin pH can be influenced by many factors, i.e. genetics, age, gender, anatomical sites, skin moisture, sweat, sebum, soaps, detergents, cosmetics, and occlusive
dressings.[1] Since the skin has an acidic pH, facial washing with soap can increase the pH level by 1.5– 2.0. The increase in pH of cleansers potentiates skin dryness and tightness and also enhances the risk of cutaneous reactions. On the other hand, lowering the pH is supposed to benefit antibacterial effect. Goodman suggested that acne cleansers should be “soap-free,” “acidic” or “pH-balanced,” and free of abrasives or alcohols, and should also have high rinsibility.[2] It has been proposed that in order to control acne, the optimal value of skin pH should be 5.4–6.0 for females and 5.5 for males.[3] In our study, it was found that all acne cleansing bars, in spite of various compositions, had an alkaline pH. Korting et al. compared the efficacy of an alkaline soap bar with an acidic syndet in 120 acne patients (a randomized controlled study) and found that after 3 months, the number of acne lesions and cutaneous irritation were lower in patients using an acidic syndet.[4]
Table 1: Comparison of the pH values of acne cleansing bars and other cleansing bars Composition and properties
9
3
9
4
9
9
Average pH by pH indicator strips
Average pH by pH meter
10.0
10.24
10.0
9.95
Soy
Niacinamide
Zinc salts
Oil control
Tea tree extracts
Benzoyl peroxide
Salicylic acid
Lactic acid
Alpha hydroxyl acids
Triclocarban
9
Triclosan
9
2
Antibacterial
Sulfur
1
Mechanical exfoliant (scrub) Polyethylene beads
Acne cleansing bars
Chemical exfoliant
Aluminum/ magnesium oxide
Sample
Ground fruit pits
Type of cleansers
9.5
9.75
10.0
10.08
5
9
10.0
10.36
6
9
10.0
10.32
7
9
8
9
9.0
9.13
10.0
10.37
Cleansing bars for oily skin
9
6.0
5.91
10
10.0
10.03
Baby cleansing bars
11
10.0
10.17
12
10.0
10.18
7.0
7.09
Syndet cleansing bars
13
General cleansing bars
14
10.0
11.31
15
10.5
10.58
Antiseptic cleansing bars
16
9
10.0
10.25
9
9.5
9.87
182
17
9
9
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
9
20
9
21
9
22
9
23
Niacinamide
a
9
9 9 9 a
9
24
9
25
9
Average pH by pH indicator strips
Average pH by pH meter
7.0
6.91
5.5
5.63
7.0
6.80
4.5
4.20
7.0
6.90
6.0
6.11
Soy
Zinc salts
Oil control
Tea tree extracts
Benzoyl peroxide
Salicylic acid 9
Triclocarban
Lactic acid 9
Antibacterial
Triclosan
Alpha hydroxyl acids 9
19
Mechanical exfoliant (scrub)
Sulfur
18
Chemical exfoliant
Polyethylene beads
Acne liquid cleansers
Composition and properties
Aluminum/ magnesium oxide
Sample
Ground fruit pits
Type of cleansers
3.0
3.0
6.0
5.84
8.0
7.99
7.0
7.12
28
6.0
6.22
26
9 9
Cleansers for oily skin
27
29
7.0
7.04
Baby cleansers
30
7.0
6.90
31
7.0
7.38
Syndet cleansers
32
7.0
7.06
General liquid cleansers
33
7.0
6.91
7.0
6.98
Antiseptic cleansers
35
8.5
8.94
9.0
9.35
a
34
9
9
36
9 9
Zinc gluconate
In general, liquid cleansers have more acidic pH than those of cleansing bars since their compositions include amphoteric, anionic, non-ionic, and silicone surfactants. They also contain emollients and humectants which lower the pH of products.[5] In this study, liquid cleansers for acne were found to have a lower pH (pH 3.0–8.0) than those of acne cleansing bars (pH 9.0–10.0).
corneocyte desquamation. The proposed anti-acne property of scrubs is that the abrasion may unroof closed comedones. However, a vigorous scrub can damage the skin surface. Therefore, scrub should not be used more than once a week and is not recommended for patients with sensitive skin. Sixty percent of the tested scrubs for acne patients in this study showed an acidic pH. In summary, the pH values of facial cleansers depend on their formulation and composition. The increase in pH potentiates skin dryness and tightness and also enhances the risk of cutaneous reactions. Apart from pH, other properties should be considered in selecting the proper cleansers for acne patients.[6]
Foams are triphasic liquids composed of oil, organic solvents, and water. They are formulated with a hydrocarbon propellant (either butane or propane), and also contain various fatty acids and alkalis which influence their wide range of pH.[5] In this study, except 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 small granules in a cleansing base for enhancing
This study would have not been possible without the 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 Composition and properties
9
39
9
9
40
9
9 9
42
9
43
Triclosan
Sulfur
Polyethylene beads
Aluminum/ magnesium oxide
Ground fruit pits
Salicylic acid
Lactic acid
Alpha hydroxy acids 41
a 9
9 9 9
9
44
General cleansing foams Acne cleansing scrubs
General cleansing scrubs a
Average pH by pH meter
5.5
5.32
7.0
7.13
10.0
9.80
10.0
10.03
10.0
10.01
6.5
6.28
10.0
10.26
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
9
b
50
Cleansing foams for oily skin
Average pH by pH indicator strips
Soy
9
9
Oil control Niacinamide
9
38
Antibacterial
Zinc salts
37
Mechanical exfoliant (scrub)
Tea tree extracts
Acne cleansing foams
Chemical exfoliant
Benzoyl peroxide
Sample
Triclocarban
Type of cleansers
9
51
9
52
9
53 54
a 9
55
9
56 57
9
58
9
9
9
59
9 9
9
60
9
61
9
62 63 64
9
9 9
9 9
9 9 9
8.5
8.52
10.0
10.15
5.5
5.31
4.5
4.63
10.0
10.22
10.0
10.09
10.0
10.22
10.0
9.94
4.5
4.38
6.5
6.33
10.5
10.59
7.0
7.13
4.5
4.52
7.5
7.54
6.5
6.56
10.0
10.36
Zinc gluconate; bzinc sulfate
would like to thank Dr. Kamolwan Pongparit for her support in manuscript preparation.
REFERENCES 1.
Nakaraj Pluetrattanabha, Kanokvalai Kulthanan, Piyavadee Nuchkull, Supenya Varothai Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand Address for correspondence: Prof. Kanokvalai Kulthanan, Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand. E-mail: [email protected]
184
2. 3.
4.
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 Sci 2006;41:153-6. Goodman G. Cleansing and moisturizing in acne patients. Am J Clin Dermatol 2009;10:1-6. Youn SH, Choi CW, Choi JW, Youn SW. The skin surface pH and its different influence on the development of acne lesion according to gender and age. Skin Res Technol 2013;19:131-6. Korting HC, Ponce-Pöschl E, Klövekorn W, Schmötzer G, Arens-Corell M, Braun-Falco O. The influence of the regular use of a soap or an acidic syndet bar on pre-acne. Infection 1995;23:89-93.
Indian Journal of Dermatology, Venereology, and Leprology | March-April 2015 | Vol 81 | Issue 2
Letters to the Editor 5. 6.
Kuehl BL, Fyfe KS, Shear NH. Cutaneous cleansers. Skin Therapy Lett 2003;8:1-4. Solomon BA, Shalita AR. Effects of detergents on acne. Clinics in Dermatol 1996;14:95-9. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.152291 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.
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]
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.
Figure 1: Profuse hyperhidrosis over back
Indian Journal of Dermatology, Venereology, and Leprology | March-April 2015 | Vol 81 | Issue 2
185
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Table 1: Patients diagnosed with syphilis Year
Patients having syphilis
Total
% of total
Male
Female
Total
STI cases
2003
7
6
13
260
5
2004
6
7
13
234
5.6
2005
7
3
10
245
4.1
2006
8
7
15
201
7.5
2007
6
2
8
179
4.5
2008
6
3
9
231
3.9
2009
7
3
10
209
4.8
2010
10
1
11
154
7.1
2011
8
4
12
167
7.2
2012
9
3
12
127
9.4
Total
74
39
113
2007
5.6
Garner MF, Backhouse JL, Daskalopoulos G, Walsh JL. The Treponema pallidum haemagglutination (TPHA) test in biological false positive and leprosy sera. J Clin Pathol 1973;26:258-60. 8. Cole MJ, Perry KR, Parry JV. Comparative evaluation of 15 serological assays for the detection of syphilis infection. Eur J Clin Microbiol Infect Dis 2007;26:705-13. 9. Ray K, Bala M, Gupta SM, Khunger N, Puri P, Muralidhar S, et al. Changing trends in sexually transmitted infections at a Regional STD Centre in north India. Indian J Med Res 2006;124:559-68. 10. Sanchez M. Syphilis. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, Editors. Dermatology in General Medicine. 7th ed. New York: McGraw- Hill 2008. p. 1955-77. 11. Siddappa K, Ravindra K. Syphilis and Nonvenereal Treponematoses. In: Valia RG, Valia AR, Editors. IADVL Textbook of Dermatology. 3rd ed. Mumbai: Bhalani Publishing House; 2008. p. 1803-47.
STI: Sexually transmitted infection
‘Prenatal syphilis’ is used to denote syphilis transmitted to the fetus in utero by the infected mother and is considered to be a better terminology than congenital syphilis.[10,11] 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: [email protected]
REFERENCES 1.
2. 3. 4.
5. 6.
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. World Health Organization. Treponemal infections. Technical reports series 674. Geneva: WHO; 1982. Thakar YS, Chande C, Mahalley AD, Saoji AM. Seroprevalence of syphilis by TPHA test. Indian J Pathol Microbiol 1996;39:135-8. 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. Archana BR, Prasad SR, Beena PM, Okade R. Making serological diagnosis of syphilis more accurate. Indian Sex J Transm Dis 2014;35:70-1. 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.
Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.152290 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 had an acidic pH [Table 1]. The pH of liquid cleansers for acne (n = 9) ranged between 3.0 and 8.0 (5 = acidic pH, 3 = neutral pH, 1 = alkaline pH). Most of the other types of liquid cleansers had neutral pH, except for antiseptic cleansers [Table 2]. Table 3 shows the pH of foams and scrubs. Most foams available in the market had an alkaline pH. The pH values of two acne foams were found to be similar to that of normal healthy skin (pH 5.4–5.9). Three acne scrubs were found to have an acidic pH and one each had a neutral and an alkaline pH [Table 3]. Alteration of the skin pH is proposed to be one of the important factors for acne development, which may be due to the change of skin resident microflora. The skin pH can be influenced by many factors, i.e. genetics, age, gender, anatomical sites, skin moisture, sweat, sebum, soaps, detergents, cosmetics, and occlusive
dressings.[1] Since the skin has an acidic pH, facial washing with soap can increase the pH level by 1.5– 2.0. The increase in pH of cleansers potentiates skin dryness and tightness and also enhances the risk of cutaneous reactions. On the other hand, lowering the pH is supposed to benefit antibacterial effect. Goodman suggested that acne cleansers should be “soap-free,” “acidic” or “pH-balanced,” and free of abrasives or alcohols, and should also have high rinsibility.[2] It has been proposed that in order to control acne, the optimal value of skin pH should be 5.4–6.0 for females and 5.5 for males.[3] In our study, it was found that all acne cleansing bars, in spite of various compositions, had an alkaline pH. Korting et al. compared the efficacy of an alkaline soap bar with an acidic syndet in 120 acne patients (a randomized controlled study) and found that after 3 months, the number of acne lesions and cutaneous irritation were lower in patients using an acidic syndet.[4]
Table 1: Comparison of the pH values of acne cleansing bars and other cleansing bars Composition and properties
9
3
9
4
9
9
Average pH by pH indicator strips
Average pH by pH meter
10.0
10.24
10.0
9.95
Soy
Niacinamide
Zinc salts
Oil control
Tea tree extracts
Benzoyl peroxide
Salicylic acid
Lactic acid
Alpha hydroxyl acids
Triclocarban
9
Triclosan
9
2
Antibacterial
Sulfur
1
Mechanical exfoliant (scrub) Polyethylene beads
Acne cleansing bars
Chemical exfoliant
Aluminum/ magnesium oxide
Sample
Ground fruit pits
Type of cleansers
9.5
9.75
10.0
10.08
5
9
10.0
10.36
6
9
10.0
10.32
7
9
8
9
9.0
9.13
10.0
10.37
Cleansing bars for oily skin
9
6.0
5.91
10
10.0
10.03
Baby cleansing bars
11
10.0
10.17
12
10.0
10.18
7.0
7.09
Syndet cleansing bars
13
General cleansing bars
14
10.0
11.31
15
10.5
10.58
Antiseptic cleansing bars
16
9
10.0
10.25
9
9.5
9.87
182
17
9
9
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
9
20
9
21
9
22
9
23
Niacinamide
a
9
9 9 9 a
9
24
9
25
9
Average pH by pH indicator strips
Average pH by pH meter
7.0
6.91
5.5
5.63
7.0
6.80
4.5
4.20
7.0
6.90
6.0
6.11
Soy
Zinc salts
Oil control
Tea tree extracts
Benzoyl peroxide
Salicylic acid 9
Triclocarban
Lactic acid 9
Antibacterial
Triclosan
Alpha hydroxyl acids 9
19
Mechanical exfoliant (scrub)
Sulfur
18
Chemical exfoliant
Polyethylene beads
Acne liquid cleansers
Composition and properties
Aluminum/ magnesium oxide
Sample
Ground fruit pits
Type of cleansers
3.0
3.0
6.0
5.84
8.0
7.99
7.0
7.12
28
6.0
6.22
26
9 9
Cleansers for oily skin
27
29
7.0
7.04
Baby cleansers
30
7.0
6.90
31
7.0
7.38
Syndet cleansers
32
7.0
7.06
General liquid cleansers
33
7.0
6.91
7.0
6.98
Antiseptic cleansers
35
8.5
8.94
9.0
9.35
a
34
9
9
36
9 9
Zinc gluconate
In general, liquid cleansers have more acidic pH than those of cleansing bars since their compositions include amphoteric, anionic, non-ionic, and silicone surfactants. They also contain emollients and humectants which lower the pH of products.[5] In this study, liquid cleansers for acne were found to have a lower pH (pH 3.0–8.0) than those of acne cleansing bars (pH 9.0–10.0).
corneocyte desquamation. The proposed anti-acne property of scrubs is that the abrasion may unroof closed comedones. However, a vigorous scrub can damage the skin surface. Therefore, scrub should not be used more than once a week and is not recommended for patients with sensitive skin. Sixty percent of the tested scrubs for acne patients in this study showed an acidic pH. In summary, the pH values of facial cleansers depend on their formulation and composition. The increase in pH potentiates skin dryness and tightness and also enhances the risk of cutaneous reactions. Apart from pH, other properties should be considered in selecting the proper cleansers for acne patients.[6]
Foams are triphasic liquids composed of oil, organic solvents, and water. They are formulated with a hydrocarbon propellant (either butane or propane), and also contain various fatty acids and alkalis which influence their wide range of pH.[5] In this study, except 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 small granules in a cleansing base for enhancing
This study would have not been possible without the support of Assistant Professor Leena Chularojanamontri. We
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Letters to the Editor Table 3: Comparison of the pH of acne cleansing foams and scrubs and other cleansing foams and scrubs Composition and properties
9
39
9
9
40
9
9 9
42
9
43
Triclosan
Sulfur
Polyethylene beads
Aluminum/ magnesium oxide
Ground fruit pits
Salicylic acid
Lactic acid
Alpha hydroxy acids 41
a 9
9 9 9
9
44
General cleansing foams Acne cleansing scrubs
General cleansing scrubs a
Average pH by pH meter
5.5
5.32
7.0
7.13
10.0
9.80
10.0
10.03
10.0
10.01
6.5
6.28
10.0
10.26
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
9
b
50
Cleansing foams for oily skin
Average pH by pH indicator strips
Soy
9
9
Oil control Niacinamide
9
38
Antibacterial
Zinc salts
37
Mechanical exfoliant (scrub)
Tea tree extracts
Acne cleansing foams
Chemical exfoliant
Benzoyl peroxide
Sample
Triclocarban
Type of cleansers
9
51
9
52
9
53 54
a 9
55
9
56 57
9
58
9
9
9
59
9 9
9
60
9
61
9
62 63 64
9
9 9
9 9
9 9 9
8.5
8.52
10.0
10.15
5.5
5.31
4.5
4.63
10.0
10.22
10.0
10.09
10.0
10.22
10.0
9.94
4.5
4.38
6.5
6.33
10.5
10.59
7.0
7.13
4.5
4.52
7.5
7.54
6.5
6.56
10.0
10.36
Zinc gluconate; bzinc sulfate
would like to thank Dr. Kamolwan Pongparit for her support in manuscript preparation.
REFERENCES 1.
Nakaraj Pluetrattanabha, Kanokvalai Kulthanan, Piyavadee Nuchkull, Supenya Varothai Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand Address for correspondence: Prof. Kanokvalai Kulthanan, Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand. E-mail: [email protected]
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2. 3.
4.
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 Sci 2006;41:153-6. Goodman G. Cleansing and moisturizing in acne patients. Am J Clin Dermatol 2009;10:1-6. Youn SH, Choi CW, Choi JW, Youn SW. The skin surface pH and its different influence on the development of acne lesion according to gender and age. Skin Res Technol 2013;19:131-6. Korting HC, Ponce-Pöschl E, Klövekorn W, Schmötzer G, Arens-Corell M, Braun-Falco O. The influence of the regular use of a soap or an acidic syndet bar on pre-acne. Infection 1995;23:89-93.
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Letters to the Editor 5. 6.
Kuehl BL, Fyfe KS, Shear NH. Cutaneous cleansers. Skin Therapy Lett 2003;8:1-4. Solomon BA, Shalita AR. Effects of detergents on acne. Clinics in Dermatol 1996;14:95-9. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.152291 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.
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]
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.
Figure 1: Profuse hyperhidrosis over back
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