(2/3 of all cutaneous side effects) [3], eczematous reactions due to photosensitivity or contact allergy, urticaria, lichenoid eruptions, fixed drug eruption and erythema multiforme to generalized exfoliative der- matitis (erythroderma), Stevens–Johnson syndrome and toxic epidermal necrolysis [4,5]. Patch-testing has been reported to be useful in the diagnosis of carbamazepine allergy in patients with eczematous, maculopapular eruptions or erythroderma [4,5]. It is a simple reliable method with few false positive results and only negligible side effects [6]. At first glance, the clinical picture of the case presented bear some resemblance to widespread ato- pic dermatitis and related erythroderma, but the sud- den onset of the eruption and the absence of atopic history helped to differentiate the condition from ato- pic dermatitis. On the other hand, the rash resembles the clinical picture of systemic contact dermatitis that is sometimes observed as generalized eruption sym- metrically distributed on axillae, eyelids and flexural folds of the elbows, neck and genitals [7]. But no allergic contact dermatitis induced by initial topical sensitization to carbamazepine is known in our patient. To the best of our knowledge, the marked involve- ment of flexural/intertriginous areas in connection with carbamazepine related eczematous reaction has not been reported before; this was the striking feature of our case. Esen O ¨ zkaya-Bayazit*, Havva Gu ¨ngo ¨r Department of Dermatology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey [1] Jones M, Fernandez-Herrera J, Dorado JM, Sols M, Ruiz M, Garcia-Diez A. Epicutaneous test in carbamazepine cuta- neous reactions. Dermatology 1994;188:18–20. [2] Konishi T, Naganuma Y, Hongo K, Murakami M, Yamatani M, Okada T. Carbamazepine-induced skin rash in children with epilepsy. Eur J Pediatr 1993;152:605–608. [3] Pelekanos J, Camfield P, Camfield C, Gordon K. Allergic rash due to antiepileptic drugs: clinical features and manage- ment. Epilepsia 1991;32:554–559. [4] Alanko K. Patch testing in cutaneous reactions caused by carbamazepine. Contact Dermat 1993;29:254–257. [5] Terui T, Tagami H. Eczematous drug eruption from carba- mazepine: coexistence of contact and photocontact sensitiv- ity. Contact Dermat 1989;20:260–264. [6] Silva R, Machado A, Brandao M, Gonc ¸alo S. Patch test diag- nosis in carbamazepine erythroderma Contact Dermat 1986;15:254–255. [7] Angelini G. Topical drugs. In: Rycroft RJG, Menne T, Frosch PJ, Benezra C, editors. Textbook of contact dermatitis. Ber- lin: Springer Verlag, 1992:484–486. * Corresponding author. Tel.: +90-212-6352939; fax: +90-212- 5310986; e-mail: bayazit@turk.net PII: S0926-9959(98)00121-4 Extramammary Paget’s disease associated with intraepithelial neoplasia of the vulva To the Editor: Vulvar localization of extramam- mary Paget’s disease (VPD) is rare [1,2]. It has been described associated with an underlying carcinoma or a neoplasm of other sites in up to 30% of reported series [1,3]. Nevertheless. in the majority of cases VPD must be included among primary neoplastic events of vulvar epithelium [1], like vulvar intrae- pithelial neoplasia (VIN) [4]. The latter, for its clin- ical and morphological heterogeneity, has been recently classified in a warty, basaloid and a well- differentiated or keratinized variant [4,5] and many pathogenic hypotheses have been suggested, so that various types of VIN may reflect different etiologies [1,4,5]. We observed a 64-year-old woman with a 3- year history of a diffuse, erythematous and itching vulvar lesion. A year before, she had undergone a vulvar biopsy that showed lichen sclerosus associated with foci of VIN 1–2. A year later, a new biopsy revealed in the same district the presence of VPD. Clinical examination, ecography and TC resulted negative for any other possible neoplastic localization and the patient was treated surgically with a simple vulvectomy. Microscopic examination revealed clear or Paget cells, larger than adjacent keratinocytes, mainly in the basal and parabasal layers of acanthotic and hyperkeratotic epidermis and in adnexal struc- tures (Figs. 1 and 2). Typical and atypical mitotic figures were also detected. No evidence of dermal invasion was observed. Moreover, surrounding epithelium exhibited variable hyperkeratosis and hap- hazardly oriented cells characterized by crowded, hyperchromatic and anisokaryotic nuclei with an increased number of mitotic figures (Figs. 1 and 2). These findings were diffuse in lower epithelial layers 183 Letters to the Editor