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THE JOURNAL OW INVESTIGATIVE DERMATOLOGY Copyright 1966 by The Williams & Wilkins Co. Vol. 47, No. 4 Printed in U.S.A. AN ELECTRON MICROSCOPIC STUDY OF CHLORPROMAZINE PIGMENTATION* KEN HASHIMOTO, M.D.,** WILLIAM WIENER, M.D.,*** JOSEPH ALBERT, M.D.,*** AND RALPH G. NELSON, MD.** The side effects resulting from large dosage and prolonged administration of chiorproma- zine have been noted in various organs (cardio- vascular, endocrine, renal, gastrointestinal) and in the hematopoietic, and central nervous sys- tems. Although the immediate dermatologic complications such as generalized eruptions, photosensitivity and contact dermatitis had been known (1, 2) since the introduction of chlorpromazine in 1953, Perrot and Bourjala (3) were the first observers to describe "un visage mauve", in a 48-year-old schizophrenic receiving chiorpromazine and thioridazine treat- ment for several years. Many similar observa- tions were reported soon thereafter (4—11). The skin pigmentation has been variously described as slate gray, blue black, metallic blue or purple. The responsible pigment substance for this peculiar pigmentation of the skin, which ap- pears golden brown in specimens stained with hematoxylin and eosin, has been attributed to melanin in most of these reports, on the basis of histochemjcal reactions. Whereas there seems to be agreement that in the dermis an accumu- lation of this pigment occurs particularly in the perivascular areas (4, 5, 8, 9), the reports about the quantity of melanin in the epidermis have varied from normal (4, 5, 8) to markedly increased (9). Perry et al. (7), Forrest et at. (12), and Satanove (9) implicated a deposition of metabolites of chiorpromazine such as 7- hydroxy-chlorpromazine, or a further metabo- lite of this compound, as imparting a purplish tinge to the skin, while Hayes et at. (8) thought that the blue color was produced by a brown pigment (melanin) in cells situated deep in the dermis by a similar optical mechanism to that of blue nevus or Mongolian spot. This investigation was supported by Research Grant GM-10299 and by a Research Grant from the Smith, Kline and French Laboratories. Received for publication December 15, 1965. aom the Department of Dermatology, Tufts University School of Medicine55 and the Derma- tology Research Laboratories, New England Medi- cal Center Hospital, Boston Massachusetts 02111 and from Medfield State ospital,*** Harding, Massachusetts. Preliminary electron microscopic studies to define the nature of this pigment and to investi- gate possible vascular changes of the involved skin (13) indicated that an increased number of melanin granules were present in all layers of the epidermis, and large hyperactive melano- cytes were found in the basal layer. Melanin granules appeared normal except for the presence of an unusually large number of fine particulate substances which were regarded as a matrix of melanin granules, premelanin granules, or proteinaceous material rich in tyrosinase (14). They showed typical cristae with periodi- cal cross bandings. In the dermis a huge num- ber of melanin granules was found to be in- gested in the lysosomes of large phagocytes. As a peculiar finding, round or confluent osmio- phiic dense bodies were found in the endotheial and perithelial cells of the vascular walls. These bodies were also seen in the lysosomes of the melanin-carrying phagocytes. While this manuscript was in preparation, Zelickson reported findings of similar ultra- structural changes in chiorpromazine-induced skin pigmentation (15), and concluded that the discoloration is not due to true melanin, but rather to the dense bodies mentioned above, which, he believed, represented a drug metabo- lite or some other form of pigment (15). REPORT OF CASES Case 1. White woman, age 39. Diagnosis: De- mentia praecox (schizophrenia). The patient had received the following medications (average doses): Thorazine: 526 gm over a period of 2 years and 4 months. $erpasil: 1.11 gm over a pe- riod of 4 months. Sparine: 0.4 gm Compazine: 0.42 gas in 1 week. Pacatal: 9 gas over a 3 month period. Trifalon: 82 gas over a period of 1 year and 5 months. Stelazine: 2.3 gm over a 5 month period. Case 2. White woman, age 49. Diagnosis: De- mentia praecox, catatonic type (Post-lobotomy). The patient had received the following medica- tions (average doses): Thorazine: 422 gas over a period of 1 year and 7 months. Serpasil: 0.32 gas in 1.5 months. Compazine: 1.05 gm over a period of 3.5 months. Stelazine: 0.14 gas in 2 weeks. Mellaril: 567 gas over a period of 1 year and 9 months. 296

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Page 1: An Electron Microscopic Study of Chlorpromazine Pigmentationskin pigmentation has been variously described as slate gray, blue black, metallic blue or purple. The responsible pigment

THE JOURNAL OW INVESTIGATIVE DERMATOLOGY

Copyright 1966 by The Williams & Wilkins Co.Vol. 47, No. 4

Printed in U.S.A.

AN ELECTRON MICROSCOPIC STUDY OF CHLORPROMAZINEPIGMENTATION*

KEN HASHIMOTO, M.D.,** WILLIAM WIENER, M.D.,*** JOSEPH ALBERT,M.D.,*** AND RALPH G. NELSON, MD.**

The side effects resulting from large dosageand prolonged administration of chiorproma-zine have been noted in various organs (cardio-vascular, endocrine, renal, gastrointestinal) andin the hematopoietic, and central nervous sys-tems. Although the immediate dermatologiccomplications such as generalized eruptions,photosensitivity and contact dermatitis hadbeen known (1, 2) since the introduction ofchlorpromazine in 1953, Perrot and Bourjala(3) were the first observers to describe "unvisage mauve", in a 48-year-old schizophrenicreceiving chiorpromazine and thioridazine treat-ment for several years. Many similar observa-tions were reported soon thereafter (4—11). Theskin pigmentation has been variously describedas slate gray, blue black, metallic blue or purple.The responsible pigment substance for thispeculiar pigmentation of the skin, which ap-pears golden brown in specimens stained withhematoxylin and eosin, has been attributed tomelanin in most of these reports, on the basisof histochemjcal reactions. Whereas there seemsto be agreement that in the dermis an accumu-lation of this pigment occurs particularly in theperivascular areas (4, 5, 8, 9), the reportsabout the quantity of melanin in the epidermishave varied from normal (4, 5, 8) to markedlyincreased (9). Perry et al. (7), Forrest et at.(12), and Satanove (9) implicated a depositionof metabolites of chiorpromazine such as 7-hydroxy-chlorpromazine, or a further metabo-lite of this compound, as imparting a purplishtinge to the skin, while Hayes et at. (8)thought that the blue color was produced by abrown pigment (melanin) in cells situated deepin the dermis by a similar optical mechanismto that of blue nevus or Mongolian spot.

This investigation was supported by ResearchGrant GM-10299 and by a Research Grant fromthe Smith, Kline and French Laboratories.

Received for publication December 15, 1965.aom the Department of Dermatology, Tufts

University School of Medicine55 and the Derma-tology Research Laboratories, New England Medi-cal Center Hospital, Boston Massachusetts 02111and from Medfield State ospital,*** Harding,Massachusetts.

Preliminary electron microscopic studies todefine the nature of this pigment and to investi-gate possible vascular changes of the involvedskin (13) indicated that an increased numberof melanin granules were present in all layersof the epidermis, and large hyperactive melano-cytes were found in the basal layer. Melaningranules appeared normal except for thepresence of an unusually large number of fineparticulate substances which were regarded as amatrix of melanin granules, premelanin granules,or proteinaceous material rich in tyrosinase(14). They showed typical cristae with periodi-cal cross bandings. In the dermis a huge num-ber of melanin granules was found to be in-gested in the lysosomes of large phagocytes. Asa peculiar finding, round or confluent osmio-phiic dense bodies were found in the endotheialand perithelial cells of the vascular walls. Thesebodies were also seen in the lysosomes of themelanin-carrying phagocytes.

While this manuscript was in preparation,Zelickson reported findings of similar ultra-structural changes in chiorpromazine-inducedskin pigmentation (15), and concluded that thediscoloration is not due to true melanin, butrather to the dense bodies mentioned above,which, he believed, represented a drug metabo-lite or some other form of pigment (15).

REPORT OF CASES

Case 1. White woman, age 39. Diagnosis: De-mentia praecox (schizophrenia). The patient hadreceived the following medications (averagedoses): Thorazine: 526 gm over a period of 2years and 4 months. $erpasil: 1.11 gm over a pe-riod of 4 months. Sparine: 0.4 gm Compazine:0.42 gas in 1 week. Pacatal: 9 gas over a 3 monthperiod. Trifalon: 82 gas over a period of 1 yearand 5 months. Stelazine: 2.3 gm over a 5 monthperiod.

Case 2. White woman, age 49. Diagnosis: De-mentia praecox, catatonic type (Post-lobotomy).The patient had received the following medica-tions (average doses): Thorazine: 422 gas over aperiod of 1 year and 7 months. Serpasil: 0.32 gasin 1.5 months. Compazine: 1.05 gm over a periodof 3.5 months. Stelazine: 0.14 gas in 2 weeks.Mellaril: 567 gas over a period of 1 year and 9months.

296

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CHLORPROMAZINE PIGMENTATION 297

Case 3. White woman, age 29. Diagnosis: Psy-chosis with mental deficiency. The patient hadreceived the following medications (averagedoses): Thorazine: 815 gm over a period of 9years. 0.1 gm I.M. p.r.n. over a 10-month period.Valium: 0.5 gm in 1 month. Sparine and Arlenein small single doses very rarely. Trilafon: 0.005—0.01 gm TM. over a 1-month period for excitement.,Slelazine: 14A gm over a period of 2 years. Tine/al:0.6 gm in 1 month. Taraclan: 24 gm in 2 months.

Case 4. White woman, age 36. Diagnosis: Psy-chosis with mental deficiency. The patient hadreceived the following medications (averagedoses): Thorazine: 90 gm over a period of Iyear and 8 months. 130 gm spansule over a periodof 1 year and 1 month, steadily increasing thedosage to 143 gm spansule in 6 months. 29.3 gmliquid over a period of 1 year and 1 month.Compazine: 2.7 gm in 1 month. Slelazine: 1.6 gmin 9 months. Taraclan: just started at 0.4 gm perday at the time of this investigation.

Case 5. White man, age 56. Diagnosis: De-mentia praecox, catatonic (Schizophrenia). Thepatient had received the following medications(average doses): Thorazine: Indefinite dosage be-fore April of 1956. 107 gm over a period of 1year and 2 months. 372 gm spansole over a 2-yearperiod. JO-2-lrifluoromelhylphenolhiazine dihydro-chloride: 1.8 gm in 4 months. Compazine: 02 gmin 2 weeks.

All five patients showed a mild to moderatepigmentation of brown to purplish tinge on theface, neck, and exposed parts of the extremities. Inaddition to the features described previously, wehave noticed that these patients often demon-strated a rapid increase of purplish tinge shortlyafter exposure to sun even S months after cessationof therapy. Also observed were bluish pinpointpunctae deeply situated in the dermis, whichbecame more apparent on stretching the skin. All5 cases also demonstrated mild to severe cornealand/or lcntieular opacities. White atrophic scarswera noted at the sites of punch biopsy excision4 months after the procedures.

MATERIALS AND METHODS

Pigmented skin from the left neck, and a con-trol specimen of normal-appearing, non-pigmentedskin from the abdomen were taken by a 6 mmpunch biopsy from each patient. All specimenswere cut into small pieces and fixed in a solutionconsisting of 1% osmic acid buffered to pH 7.5with veronal buffer, and adjusted to physiologicalosmolarity by the addition of 4.5% sucrose. Thespecimens were then dehydrated through a gradedseries of alcohols and embedded in Araldite. Sec-tions were cut on an LKB IJitrotome and stainedwith 1% uranyl acetate in 50% ethanol, and then,before completely dried, with Reynolds' lead ci-trate (16). Sections were examined with an RCAEMU-3G electron microscope. Some specimenswere frozen and cut at 7 in a crynstat. Sectionswere stained for dopa oxidase, using a solution of

DL dopa 1.0 mg/l.0 ml in 0.1M phosphate bufferat pH 7.1, and for acid phosphatase (17).

REsULTS

The basal layer of the epidermis accommo-dated dopa-pcsitive melanocytes at regular in-tervals (Fig. 1). By the electron microscopethese melanocytes could he easily differentiatedfrom the surrounding basal cells by (1) thelight cytoplasm with paucity of tonofilaments,(2) abundance of rough-surfaced endoplasmiereticulum, and (3) the presence of all gradientsof sizes and densities of the premature melaningranules at their formation in the melanosomes,and a rather small number of very dense, largemature granules (Fig. 1). These melanoeyteswere strongly dopa-positive (cf. Fig. 4). Thebasal cells and the cells in the squamous, granu-lar and horny layers contained an abnormallyincreased number of melanin granules, either in-tact or partially disintegrated (Fig. 2). Prac-tically all epidermal cells contained somemelanin granules (Fig. 1). Melanin granulesin the basal cells and lower squamous cellswere cemposad of several longitudinal cristaewith many fine crass-Landings or Lead-ings, and were confined within a membrane(Fig. 2). Also found within this membrane werenumerous, fine electron-dense particles (Fig. 2).These particles were similar in size to RNPparticles and were compatible with those foundin the normal (18) as well as in melanomamelanocytes (14). Wellings and Siegel (14) re-garded them as the matrix for the melaningranules consisting of proteins related to tyro-sinase. The increased number of these particlesand the rough-surfaced endoplasmic reticulumprobably signify a cellular hyperactivity. Thescarcity of mature melanin granules in these hy-peractive melanoeytes could be explained if weassume that as soon as granules become ma-ture, they are injected into the surroundingepidermal cells. Except for these signs of cellu-lar hyperactivity, and the resultant huge num-ber of melanin granules in all layers of the epi-dermis, the epidermal ultrastruetures werewithin the normal limit. No abnormal sub-stances, as will be described below, were foundin the epidermis. These findings agree with thoseof Zeliekson (5).

In the upper and middle sections of the der-mis there were aggregations of large phagocytes,mainly perivascular in location. In histoehemi-

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d•. •

298 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

FIG. 1. Survey picture of the pigmented skin. There are two melanocytes (M) with rela-tively few, small melanin granules. Practically all epidermal cells contain some melaningranules (arrows). Otherwise, the epidermis is essentially normal. C: dermal connectivetissue. G: granular layer. H; horny layer. p: phagocyte with dense body. X 2850.

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CHLORPROMAZINE PIGMENTATION 299

Fic. 2. Ba8al cell with numerous mature melanin granules. Each granule is confined withinlimiting membranes and intermingled with fine matrix particles. Some granules show longi-tudinal cristae and cross-bandings. C: collagen. Bm: basement membrane. N: nucleus. T:tonofilaments. X 26,100.

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300 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

cal sections these phagocytes were stainedstrongly for acid phosphatase, indicating thatthey contain active lysosomes. These phago-eytes contain in their lysosomes (1) intactand/or fragmented melanin granules, (2) elec-tron dense particles similar to those matrix par-ticles described above in the melanin granulesof the basal melanoeytes, and (3) round to ovalbodies of various electron density, measuring upto 3s (Figs. 3, 4). Since neither melanin gran-ules nor these matrix particles were seen in thesubepidermal connective tissue, it appeared pos-sible that the melanin-carrying phagoeytes hadengulfed all the dendrites of the basal melano-cytes projected into the dermis. The endothelialcells of various-sized vessels showed numerouspinocytotie vesieles along the vascular luminaand also contained bodies of various sizes andelectron density similar to those describedabove as being found in the large phagocytes.Small bodies were round to oval, while manyof the large bodies showed bizarre shapes (Figs.5, 6). In those which had low electron density,either concentric fine lamellar structures (Fig.5) or small particles (Fig. 6) were revealed. Itwas thought that these bodies were not de-posited in the cytoplasm haphazardly, but wereconfined in the lysosomes since these fine lamel-lar structures were identical to the residualbodies of lysosomes (19, 20, 21), and since insome dense bodies double membranes of lyso-somes were observed surrounding them. Smallparticles were unidentifiable but could beeither ferritin or substances related to theehlorpromazine complex. The substance whichformed the bizarre dense bodies was thought tohave (1) derived from the blood stream, (2)been taken into the endothelial cells by thepinocytosis of the endothelial cells and (3)stored and tried to be digested in the lyso-somes. Then, they seemed to be transferred tothe perithelial cells and perivaseular phagocyteswithout undergoing many changes since thesame bodies were always present in these cells.In order to explain the presence of the samebodies in the migratory melanin-carrying phago-eytes it may be assumed that either theseperithelial phagoeytes with dense bodies be-came freed from the perivaseular lodging orthat these bodies, once discharged from theperithelial cells into the connective tissue, werethen picked up by the migratory phagoeytes.

At first, we thought that the first assumptionwas the more likely since no similar densebodies were encountered in the connective tis-sue of the dermis of our materials. However,the recent report by Zelickson (15) has shownthe presence of these bodies in the connectivetissue, making the second assumption alsoprobable. These bodies were only occasionallyseen in the non-pigmented control skin. Nodopa-positive cells were present in the dermis ofboth pigmented and non-pigmented areas (Fig.4).

DISCUSSION

The assumption made by the previous in-vestigators, on the basis of various histo-chemical stains, that the blue-black skin of theehlorpromazine-induced hyperpigmentation con-tains melanin was confirmed by the electronmicroscope. Melanin granules, however, canonly be identified positively by the electronmicroscope by characteristic eristae, cross-band-ings and fine matrix particles. Fontana'ssilver nitrate method for melanin as used byprevious workers (4, 5, 8), though fairlyspecific, is not an absolute method for identify-ing melanin because any reducing agent ofsilver can yield a positive reaction. Therefore,the demonstration of typical melanin granulesby the electron microscope was necessary inorder to state categorically that at least aportion of the hypcrpigmentation, or as amatter of fact, probably the majority of it, wasdue to an increased epidermal and dcrmalmelanization.

Since dopa-positivc mclanocytes were onhdemonstrable in the basal layer, it is apparenthat the melanin granules in the dermal phagocytes were spilt over from the overloadedepidermal melanocytes. The mechanisms in-volved in the transfer of the mature melaningranules from the basal melanocytes to thedermal phagocytes are not clear. The transfermay be achieved by a phagocytosis of theentire dendrite, which contains an abundanceof mature melanin granules, by the dermalphagocytes, or by the dropping of melaningranules into the dermis through a breakingdown of the basal melanocytes. It is, however,expected that these melanin granules are storedin the lysosomes of the dermal phagocytes.Strong acid phosphatasc activity in these cells

Page 6: An Electron Microscopic Study of Chlorpromazine Pigmentationskin pigmentation has been variously described as slate gray, blue black, metallic blue or purple. The responsible pigment

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CHLORPROMAZINE PIGMENTATION 301

FIG. 3. Dermal phagocye which has ingested melanin granules (m), matrix particles whichare similar to those shown in Fig. 2, and dense bodies (d) in lysosomes. Note that the matrixparticles are always associated with melanin granules. Arrows: lysosomal membrane. C: col-lagen. E: elastic fiber. >< 10,440.

as demonstrated in this study supports the con-cept of lysosomal localization of these melaningranules and other substances, and agrees withZelickson's statement (5).

With regard to the dense bodies in theendothelial cells, in the perivascular cells,and in the dermal phagocytes, the electronmicroscope is not a suitable tool to determine

whether or not they are related to chlor-promazine. It is only conjectured because oftheir electron density that they could be alipoprotein complex, which might be cosiju-gated with chlorpromazine or its metabolites.Their distribution suggests that they derivedfrom the blood stream, and their presence in thepigmented skin in huge amounts suggests that

Page 7: An Electron Microscopic Study of Chlorpromazine Pigmentationskin pigmentation has been variously described as slate gray, blue black, metallic blue or purple. The responsible pigment

302 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

FIG. 4. Dense bodies (D), melanin granules (m) and matrix particles are confined withinlysosomes. Dense bodies show various sizes and densities. C: collagen. N: nucleus. >< 30,000.Insert: Dopa stain of pigmented lesion. Dopa-positive melanocytes (arrows) in the basallayer are stained black while melanin granules in the dermal phagocytes are clumped intoseveral golden-colored masses (thick arrows). X 113.

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Page 8: An Electron Microscopic Study of Chlorpromazine Pigmentationskin pigmentation has been variously described as slate gray, blue black, metallic blue or purple. The responsible pigment

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CHLORPROMAZINE PIGMENTATION 303

FIG. 5. Vascular dense bodies in the endothelial cells (E) and in the perithelial cells (F).It is seen that small bodies become confluent and grow into larger ones. Also seen are variousdegrees of density; some are faint revealing lamellar structure (1) and others completelyblack. Some light bodies are stippled with tiny particles (arrows). L: Vascular lumen.X 6,120.

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304 THE J OTJRNAL OF INVESTIGATIVE DERMATOLOGY

Fm. 6. Vascular dense bodies an high magnification. Dense bodies are found in bath endo-thehal cells (E) and in perithelial cells (P). One relatively hght body (1) contains numerousfine particles. There are many pinocytotic vesieles (p) along the luminal harder of the endo-thelial cells. C: perivascular eallagen and reticulin. 1: tanofilaments. L: Vascular lumen, N:nuclei. >< 14,226.

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CHLORPROMAZINE PIGMENTATION 305

they might play a causative role in the hyper-pigmentation through, for instance, a stimula-tion of melanocytes. Hyperpigmentation inargyria has been said to be due not only tosilver deposits, but also to the over-productionof melanin stimulated by the presence ofsilver (22).

It is also not clear whether these bodies arerelated to the purple-colored substance whichwas reported by Satanove (9) to give rise to areflectance curve different from melanin. Weare in complete agreement with Zeickson (15)including the observation that these densebodies may represent a drug metabolite re-lated to chlorpromazine. We are, however, notready to conclude that the discoloration is dueto these dense bodies, simply because thesedense bodies were rather small in number incomparison to the number of the melanin gran-ules in the pigmented lesions of our material.Furthermore, any colored substance in thedermis cannot be observed in its original colorthrough the thickness of the overlying dermisand epidermis especially when the overlyingepidermis is heavily pigmented. Nevus of Ota orMongolian spots are good examples of thiscategory. Needless to say, electron dense sub-stances after osmic acid fixation are not neces-sarily dense in the living conditions; thesedense bodies could be colorless in the patients'skin.

We would like to conclude, therefore, that inour material, peculiar discoloration producedin the skin by prolonged high dosage of chlor-promazine therapy is probably due mainly toan increased epidermal and deep dermalmelanization, although the possibility that theelectron dense bodies in the dermal phagocytesand in the vessel walls may be a partial, contrib-utory factor for the discoloration cannot beruled out. A disfunction of blood vessels due tothe deposit of these dense bodies may add acyanotic hue to the color complex of the skin ofthese patients. The last point was inferredfrom the findings in angiokeratoma corporisdiffusum (Fabry) in which endothelial cells ofthe dermal vessels are weakened by the presenceof similar lysosomal bodies (21) to produce anangiomatous dilatation.

SUMMARY

1. Skin specimens of five Caucasian patientswith chiorpromazine-induced, purplish hyper-

pigmentation on the exposed skin were studiedhistochemically as well as by the electron micro-scope.

2. Large, dopa-positive melanocytes werefound in the basal layer, and all layers of theepidermis contained an increased number ofmelanin granules, accounting for a part of thehyperpigmentation. Melanin granules appearednormal, but there was an unusually large amountof fine particulate substance (premelanin gran-ules) within the melanosomes.

3. In the dermis a large number of melaningranules was found ingested in the lysosomesof large phagocytes. These phagocytes demon-strated a strong acid phosphatase activity butno dopa reaction. Round or bizarre-shapeddense bodies were found in the lysosomes ofthese large phagocytes as well as in the lyso-somes of endothelial and perithelial cells ofdermal blood vessels. These dense bodies werefound in greater concentration in the pigmentedareas than in non-pigmented abdominal skinand are thought to be related to metabolites ofchiorpromazine.

4. Although these dense bodies, related tochlorpromazine metabolites, could stimulatemelanocytes to produce an abnormally largeamount of melanin, it was, however, not clearwhether or not these bodies were directly re-sponsible for the purplish hyperpigmentationcharacteristically seen in these patients.

REFERENCES

1. Epstein, J. H., Brunsting, L. A., Petersen, M. C.and Schwarz, B. E.: A study of photosensi-tivity occurring with chlorpromazine ther-apy. J. Invest. Derm., 28: 329, 1957.

2. Cahn, M. M. and Levy, E. J.: Ultravioletlight factor in chlorpromazine dermatitis.Arch. Derm. (Chicago) 75: 38, 1957.

3. Perrot, M. and Bourjala, M.: Cas Pour Diag-nostic: "Un visage mauve." Bull. Soc. Franc.Derm., 69: 631, 1962.

4. Greiner, H. C. and Berry, K.: Skin pigmenta-tion and corneal and lens opacities with pro-longed chlorpromazine therapy. Canad. Med.Ass. J., 90: 663, 1964.

5. Zelickson, A. S. and Zeller, H. C.: A new andunusual reaction to chiorpromazine.J.A.M.A., 188: 394, 1954.

6. Feldman, P. E. and Frierson, B. D.: Dermato-logical and ophthalmological changes associ-ated with prolonged chiorpromazine therapy.Amer. J. Psychiat., 121: 187, 1964.

7. Perry, T. L., Culling, C. F. A., Beny, K. andHansen, S.: 7-hydroxychlorpromazine: Po-tential toxic drug metabolite in psychiatnepatients. Science, 146: 81, 1964.

8. Hays, G. B., Lyle, Jr., C. B. and Wheeler, Jr.,

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306 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY

C. E.: Slate-gray color in patients receivingchlorpromazine. Arch. Derm. (Chicago) 90:471, 1964.

9. Satanove, A.: Pigmentation due to pheno-thiazines in high and prolonged dosage.J.A.M.A., 191: 263, 1965.

10. Tredia, L. M., Schiele, B. C. and McClanahan,W. S.: The incidence and management ofchiorpromazine. Skin-eye syndrome. Mmne-sota Med., 48: 569, 1965.

11. Barsa, J. A. and Saunders, ,J. C.: A peculiarphotosensitivity reaction with chiorproma-sine. Psychopharmacologia, 7: 138, 1965.

12. Forrest, F. M., Forrest, I. S. and Roizin, L.:Chemical and biochemical and post-mortemstudies on patient treated with chiorproma-zinc. Agressologie, 4: 259, 1963.

13. Hashimoto, K., Wiener, A. and Albert, J.:Electron microscopic studies of chiorproma-zine pigmentation. Clin. Res., 13: 530, 1965.

14. Wellings, S. R. and Siegel, B. V.: Electronmicroscopic studies on the subcellular originand ultrastructure of melanin granules inmammalian melanomas. Ann. N. Y. Acad.Sci., 100: 548, 1963.

15. Zelickson, H. S.: Skin pigmentation and chior-promazine. J.A.M.A., 196: 670, 1965.

16. Reynolds, E. S.: The use of lead •citrate athigh pH as an electron opaque stain in elec-tron microscopy. J. Cell Biol. 17: 208, 1963.

17. Barka, T. and Anderson, P. J.: Histochemicalmethods for acid phosphatase using hexa-zonium pararosaniline as coupler. J. Histo-chem. Cytochem., 10: 719, 1962.

18. Drochmans, P.: Melanin granules. In: Interna-tional Review of Experimental Pathology,Vol. II, ed. by Richter, G. W., p. 357, NewYork, Academic Press, 1962.

19. DeDuve, C.: The lysosome. Sci. Amer., 208:64, 1963.

20. Hashimoto, K. and Lever, W. F.: Kaposi'ssarcoma. Histochemical and electron micro-scopic studies. J. Invest. Derm., 43: 539, 1964.

21. Hashimoto, K., Gross, B. G. and Lever, W. F.:Angiokeratoma corporis diffusurn (Fabry).Histochemical electron microscopic studies ofthe skin. J. Invest. Derm., 44: 119, 1965.

22. Lever, W. F.: Histopathology of the shin,page 196, Philadelphia, Lippincott, Thirdedition, 1961.