be due to a role played by TNF in the pathogenesis of TEN-like lesions. Although promising results were obtained in our study, a larger number of patients need to be evaluated in order to propose etanercept as a therapeutic agent in TEN-like ACLE. Monica Napolitano, MD, PhD, Anna Rita Giampetruzzi, MD, Dario Didona, MD, Massimo Papi, MD, and Biagio Didona, MD Istituto Dermopatico dell’Immacolata-IRCCS, Rome, Italy Funding sources: None. Conflicts of interest: None declared. Correspondence to: Biagio Didona, MD, I Derma- tological Unit, Istituto Dermopatico dell’Imma- colata-IRCCS, Via Monti di Creta 104, 00167 Rome, Italy E-mail: b.didona@idi.it REFERENCES 1. Ziemer M, Kardaun SH, Liss Y, Mockenhaupt M. Stevens- Johnson syndrome and toxic epidermal necrolysis in patients with lupus erythematosus: a descriptive study of 17 cases from a national registry and review of the literature. Br J Dermatol 2012;166:575-600. 2. Gubinelli E, Canzona F, Tonanzi T, Raskovic D, Didona B. Toxic epidermal necrolysis successfully treated with etanercept. J Dermatol 2009;36:150-3. 3. Fischer M, Fiedler E, Marsch WC, Wohlrab J. Antitumour necrosis factor-alpha antibodies (infliximab) in the treatment of a patient with toxic epidermal necrolysis. Br J Dermatol 2002;146:707-9. 4. Downey A, Jackson C, Harun N, Cooper A. Toxic epidermal necrolysis: review of pathogenesis and management. J Am Acad Dermatol 2012;66:995-1003. 5. Aringer M, Smolen JS. Efficacy and safety of TNF-blocker therapy in systemic lupus erythematosus. Expert Opin Drug Saf 2008;7:411-9. http://dx.doi.org/10.1016/j.jaad.2013.07.036 Bowen disease of the vulva successfully treated with intraarterial infusion chemotherapy To the Editor: For Bowen disease (BD) of the vulva, management includes vulvectomy, laser ablation, and topical application. 1,2 Limitations of these treatments include high recurrence rates and risk of disfiguration, impaired function, and psychosexual sequelae. 2 To avoid anatomic and functional deficits, the patients presented here- in were treated by intraarterial (IA) infusion chemotherapy. Case 1. A 60-year-old woman presented with a well-defined erythematous polypoid plaque with erosive surface on the labia major and minor (Fig 1, A). Case 2. 61-year-old woman presented with a 4.2- 3 3.9-cm pinkish brown plaque on the vulva and perineum with invasion to the anus. Pathology reports of both cases showed BD. Consent for treatment was obtained from the patients. The implantable port-catheter system (Jet Port Plus Allround, PFM, Cologne, Germany) was used. The catheter was inserted through the lateral circumflex artery into the abdominal aorta with the tip placed at the level of the third lumbar vertebra. Each patient was infused continuously with 50 mg methotrexate (MTX) every 24 hours using a portable pump (CADD-1, Deltec, St Paul, MN). Citrovorum factor 15 mg was given intramuscularly every 12 hours during the period of MTX infusion. In total, MTX 500 mg was given to the case 1 patient and was stopped because of decreased white blood cell count (2700/mm 3 , nadir, grade II, according to WHO classification). MTX 620 mg was given to the patient in case 2 and was stopped because of a rash over the neck and chest (grade II). Both patients were followed up at the outpatient clinic with intermit- tent arterial infusion of 50 mg MTX weekly. In both patients, the tumor disappeared after 3 months (Fig 1, B). Three months after treatment, incisional biopsies at 2 separate sites showed no residual tumor in the patient in case 1. For precautionary measures, patients were given one shot infusion of 50 mg MTX every 1 to 2 weeks for up to 1 year. In case 1, the patient received 250 mg 5-fluorouracil every 2 weeks for 1 additional year. She was in sustained complete remission at 4 years, her most recent follow-up, as was the patient in case 2 at 3.5 years. Due to its multifocal nature, vulvar BD presents a therapeutic challenge with a high rate of recur- rence. Vulvar BD has a certain invasive potential both in untreated patients (9%) and in patients after treatment (3.3%). 3,4 The treatment is aimed at the removal of all visible lesions to exclude the presence of an occult carcinoma. 1,2,4 However, the sequelae from disrupting vulvar appearance and function may lead to psychosexual problems in more than half of women following vulvectomy. 1,2,4 IA infusion chemotherapy has the advantage of delivering a high concentration of drug to the whole pelvic area to cover all vulvar lesions. It has been used in our clinic to treat penile carcinoma since 1985 and produced good results with the preservation of penile anatomy JAM ACAD DERMATOL VOLUME 69, NUMBER 6 Letters e305