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Adverse reactions to drugs usually affect the skin, but do not usually result in death or disability. Some of the most common severe skin reactions to drugs are described and reviewed. The classic clinical features of reactions known as Stevens-Johnson syndrome, toxic epidermal necrolysis, hypersensitivity syndrome, vasculitis and serum sickness, skin necrosis from anticoagulants, and angioedema are covered. Physicians may need to become very familiar with the clinical features of these skin reactions to prevent serious consequences from developing. Early recognition of the symptoms and discontinuation of the drug thought to cause the reactions are critical. Patients who have experienced toxic epidermal necrolysis and hypersensitivity syndrome should tell their first-degree relatives because they, too, may have similar reactions.

Patients with HIV infection often develop skin diseases including those caused by adverse reactions to drugs. Among 684 individuals with HIV infection, 79% had one or more skin disease. Eight percent of the skin diseases diagnosed among these patients were caused by an adverse reaction to a drug. Forty-three hospitalizations occurred among the patients for different types of skin disease. Fifteen of the hospitalizations were for cellulitis and 13 were for adverse drug reactions. Individuals in an advanced stage of HIV infection were more likely to develop a skin disease than those in an earlier stage. Drugs that often caused complications affecting the skin included trimethoprim-sulfamethoxazole, sulfadiazine, trimethoprim-dapsone and aminopenicillins.

Basal-cell cancers and squamous-cell cancers are both nonmelanoma skin cancers accounting for more than a third of cancer cases in the US. Nonmelanoma cancers primarily affect whites and are caused mainly by radiation from the sun. The most effective way to prevent these types of cancer is to avoid sun exposure, especially during the middle of the day, and to use sunscreen and wear protective clothing when outdoors. About 80% of basal-cell carcinomas appear on the head and neck and 80% of squamous-cell carcinomas caused by the sun appear on the arms, head and neck. About 50% of all nonmelanoma patients will develop a new skin cancer within five years of the first diagnosis. Several types of surgery, chemotherapy and radiotherapy are used to treat nonmelanoma. Early detection of these cancers is the most important factor in reducing both the severity and the cost of treatment.

Phenytoin may not be an effective treatment for patients with recessive dystrophic epidermolysis bullosa, a rare genetic disorder characterized by blistering and scarring of the unusually fragile skin. Twenty-two patients with this disease were treated for five to seven months with either phenytoin or a placebo (an inactive substance). The treatments were then reversed, after a two-month break. Disease activity did not decrease during treatment with phenytoin, compared to treatment with a placebo. An average 7% decrease occurred in the number of blisters and erosions over the entire body during treatment with phenytoin, compared to an average 6% increase during treatment with a placebo. The size of three plaques, or specific areas containing blisters and erosions, decreased an average of 0.4% during phenytoin treatment and increased an average 0.2% during the placebo treatment. The number of blisters and erosions within each of the three plaques declined an average of 12% during treatment with phenytoin, compared to an average 31% increase during treatment with the placebo. These differences were not significant.

People who have been treated for basal cell and squamous cell skin cancer have a greater risk of developing skin cancer again. Of 1,805 people diagnosed with either basal cell or squamous cell skin cancer between 1980 and 1986, half developed cancer again within five years of their first diagnosis. They were much more likely to develop the same type of cancer - basal cell or squamous - that they had been diagnosed with initially. The risk of developing cancer again was greater in men, older individuals, California residents and those who had previously been diagnosed with cancer more than once. Those who had sensitive skin or skin damaged by the sun were more likely to develop cancer again. Smokers were twice as likely to develop squamous cell skin cancer again; the risk was not as high in former smokers. Squamous cell skin cancer can be deadly; consequently, people with a history of squamous cell skin cancer should be closely followed., Objective.--The primary aims of this study were to assess risk of subsequent basal and squamous cell skin cancer among patients with a prior history of these tumors and to examine these risks in relation to patient characteristics and life-style factors. Design.--Follow-up of participants in a randomized trial of betacarotene as a possible skin cancer preventive agent. Setting.--Clinical centers in Los Angeles, Calif, San Francisco, Calif, Minneapolis, Minn, and Hanover, NH. Participants.--Patients (n= 1805) who were diagnosed as having a basal or squamous cell skin cancer between January 1980 and February 1986 and were free of skin cancer at study entry. Main Outcome Measure.--Time from study entry to first new occurrence of basal and squamous cell skin cancer. Results.--The estimated risk of developing one or more new skin cancers was 35% at 3 years and 50% at 5 years. New skin cancers tended to be of the same cell type as the previous skin cancers. For both basal and squamous cell skin cancer, risk was higher among patients who were male, were over the age of 60 years, had more prior skin cancers, had severe actinic skin damage, or who burned easily with sun exposure. Compared with those who had never smoked, the rate of subsequent squamous cell skin cancer was higher among current smokers (rate ratio, 2.01; 95% confidence interval, 1.21 to 3.34) and former smokers (rate ratio, 1.62; 95% confidence interval, 1.07 to 2.47) and increased with both duration and amount smoked. There was no clear relationship between smoking and basal cell skin cancer; the rate appeared lower among heavy smokers but was unrelated to duration of smoking. Conclusions.--Persons with a prior nonmelanoma skin cancer had a substantial 5-year risk of developing another tumor of the same histologic type. Number of previous skin cancers, solar damage, and skin sensitivity to sun exposure were particularly related to this risk. The increased risk of squamous cell skin cancer associated with cigarette smoking merits further study. (JAMA. 1992;267:3305-3310)

In addition to caring for patients with sudden illnesses or trauma, emergency departments provide primary care for other groups of individuals as well. For both trauma and primary care patients, the emergency room leads to admission to the hospital, with important reimbursement and public policy implications. During the past decade, the number of poor and uninsured patients admitted through emergency departments increased disproportionately. These patients are usually sicker and cost more to care for than patients with similar diagnoses who are admitted by their physicians. To determine whether emergency room admissions differ from other admissions, and to evaluate the resulting cost implications, 20,089 patients at 5 different hospitals were interviewed over a 6-month period. DRGSCALE, a system developed by SysteMetrics Inc., was used to judge severity of illness. At all five hospitals, patients admitted through the emergency department required substantially more resources than nonemergency patients, even after adjusting for age, diagnosis related group (DRG), severity of illness, and income. Uninsured persons were 3.1 times more likely, on average, to be admitted to the hospital through the emergency department than those with private health insurance. Single, nonwhite, lower-income patients were more likely to be admitted through the emergency department, and to require more care; however, hospital reimbursement for their care is based on the national Medicare DRG system of fixed payments based only on the admitting diagnosis. For this reason, hospitals with high occupancy rates are likely to limit emergency care, thus limiting access to medical care for the poor and the elderly. DRGSCALE was a strong predictor of length of hospital stay, and is an important addition to the DRG in predicting a patient's use of medical resources. (Consumer Summary produced by Reliance Medical Information, Inc.)

Maintaining the quality of care and preventing rising costs are currently major objectives in medicine. Quality assurance studies have concentrated on inpatient care. The performance of a physician is assessed by special committees, conferences on disease and death rates, and departmental review committees, which evaluate results from anatomic and surgical pathological studies. The accuracy of the physician's diagnosis; the appropriateness of the medical procedure; and the possible causes of unfavorable outcomes are examined. Ambulatory surgery, or operations performed on an outpatient basis, accounted for a large proportion of the 40 million visits to physicians in 1985. Most cases of ambulatory surgery involve removal of a benign or malignant skin lesion. The quality, cost, and appropriateness of care for this type of ambulatory surgery has not been extensively assessed. In this study, the diagnostic accuracy and appropriateness of treatment of seborrheic keratoses (a common, benign skin disorder) were analyzed. This skin disease is characterized by the development of keratotic, or horny skin growths, and increases with age. Seborrheic keratoses does not require surgery unless the lesions become irritated, inflamed, or cosmetically displeasing. Tissues from 527 seborrheic keratoses removed by 133 clinicians who were affiliated with four different institutions were examined. The diagnosis before surgery was correct in only 49 percent of cases, with dermatologists providing the greatest diagnostic accuracy. The correct procedure for pathological diagnosis was carried out in only 50 percent of cases. The likelihood of receiving appropriate care was eight times greater in cases in which lesions were accurately diagnosed before surgery. These findings suggest that clinicians often fail to make a correct diagnosis before removing a skin lesion. In addition, more extensive surgery than necessary is often used to confirm a diagnosis pathologically. The approach to quality assurance used in this study may be an effective and inexpensive method for monitoring the quality of ambulatory surgical care. (Consumer Summary produced by Reliance Medical Information, Inc.)

The concept of the diagnosis-related group (DRG) originated to restrain the growth of medical costs by placing limits on the payments made for diseases within a particular group. Although the method seems to be having the desired effect, at least for Medicare payments, there are indications that undesired effects are taking place as well. There has been a suggestion that hospitals are reticent to provide care for those patients likely to exceed average costs, especially for those of lower socioeconomic status. If the average costs for patients of lower socioeconomic status are indeed higher, then payments based on DRGs will be providing incentives to restrict access to health care. To determine if different patients groups do incur different costs for comparable illnesses, a total of 16,908 patients at five Massachusetts hospitals were interviewed. Only obstetric and psychiatric patients were excluded from the study. On the basis of the interviews, which revealed the patients' incomes, occupations, and education, patients were divided into three social strata. When compared by equivalent age, severity of illness, and DRG, the lowest strata incurred higher charges and spent more time in the hospital than did those in higher strata. The differences were up to 21 percent for length of stay and 13 percent for charges incurred. These results require careful consideration. For hospitals treating substantial numbers of poorer individuals, the absence of supplementary payments for the care of patients requiring more services may put disproportional pressure on these hospitals. (Consumer Summary produced by Reliance Medical Information, Inc.)

The first clearly traced relationship between environmental exposure and development of cancer was achieved by Percival Pott in 1775. While Pott found that cancer of the scrotum could be caused by tar pitch, evidence has now accumulated that the same cancer can be caused by a treatment for psoriasis which has been in use since 1975. A total of 1,380 patients received psoralens and ultraviolet A radiation (PUVA) treatment for psoriasis in 1975 and 1976. PUVA consists of treatment with methoxsalen (8-methoxypsoralen), a photosensitizing compound, and ultraviolet A illumination. Ultraviolet A is light of wavelength from 320 to 400 nanometers; it is a longer and less energetic wave than ultraviolet B, which extends from 290 to 320 nanometers. Both forms of ultraviolet are known to increase the risk of skin cancer; a review of the 892 men among the patients who received PUVA therapy reveals that the risk to the penis and scrotal sac is even greater than the risk of skin cancer in general. Of the 892 male patients, 14 developed a total of 30 squamous cell carcinomas of the genitals. For those receiving the highest dose of PUVA, this represents a risk almost 300 times the risk of white males in general. Furthermore, while the ratio of squamous cell carcinomas of the head and neck to those of the genitals is 83 to 1 in the general population, the ratio was only 3 to 1 in the study population. This indicates a particular susceptibility of the genitals, which may be due to the relative inability of this region to develop protective tanning. When equivalent doses of PUVA were controlled for in the statistical analysis, it was found that the shorter wavelength ultraviolet B alone also had an independent influence, increasing the risk of genital cancer roughly fourfold. Although squamous cell carcinoma of the vulva is more common in the general population than are tumors of the penis, only one case was seen among the women in the PUVA study, suggesting that the greater exposure of the male genitalia is a key factor in the risk of genital cancer. Since many individuals, including over 1 million individuals a day in tanning salons, have some degree of ultraviolet exposure for therapeutic or cosmetic reasons, extra care should be taken to shield the genitalia. (Consumer Summary produced by Reliance Medical Information, Inc.)