Skin/Integumentary System

Dermatology Assessment Guidelines

• Evaluate the whole patient, not just the skin condition. Assess for possible transmission or contagion risk.
• Key questions to ask:
  • Where did the issue first appear? (Face, torso, extremities, genitals)
  • How long has it been present?
  • Does it itch?
  • Is the patient otherwise healthy?
    • Conditions like rosacea, keratosis pilaris, and seborrheic dermatitis are often skin-limited.
  • Is the patient uncomfortable but not systemically ill?
    • Itching, burning, pain → Could indicate scabies or shingles.
  • Is the patient systemically unwell (fever, fatigue, appetite loss, weight loss, malaise)?
    • Possible conditions: Varicella, toxic epidermal necrolysis, Lyme disease, lupus.
  • Are there primary lesions only, or primary and secondary?
    • Where did the oldest lesion first appear, and when?
    • Where did the newest lesion appear, and when?
    • Primary lesions: Direct result of disease, not altered by external factors.
      • Example: Vesicle (<1 cm, fluid-filled) – seen in varicella, herpes, shingles.
    • Secondary lesions: Altered by treatment or disease progression.
      • Example: Crust – formed by dried serum/blood when a vesicle ruptures.

Smallpox

• Declared eradicated in 1977.
• Infects respiratory and oropharyngeal surfaces; 2-week incubation period.
• Symptoms mimic flu, with large nodules primarily on the face, arms, and legs.
• Mortality rate: 20-50%.
• Post-exposure vaccine (within 3-4 days) can reduce severity.

Common Skin Lesions & Their Characteristics

Lesion Type	Description	Example Conditions
Annular	Ring-shaped with central clearing	Lyme disease (bull’s eye lesion)
Bulla	Fluid-filled blister >1 cm	Burns
Clustered	Grouped lesions without a specific pattern	Herpes
Confluent/Coalescent	Merging lesions forming larger patches	Psoriasis
Cyst	Encapsulated, raised, fluid-filled lesion	Intradermal cyst
Lichenification	Thickened skin from chronic itching/rubbing	Eczema
Linear	Appears in streaks	Poison ivy
Macule	Flat, non-palpable discoloration <1 cm	Freckle
Maculopapular	Flat discoloration with small raised papules	Viral exanthem
Nodule	Solid, raised lesion 0.5–2 cm (>2 cm = tumor)	Lipoma
Papule	Small, solid elevation <0.5 cm	Mole
Patch	Flat discoloration >1 cm	Vitiligo
Petechiae	Small red-purple spots <1 cm, do not blanch	Thrombocytopenia
Plaque	Elevated, flat lesion >1 cm	Psoriasis
Purpura	Red-purple discoloration that doesn’t blanch	Meningococcemia
Pustule	Small vesicle filled with pus	Impetigo
Reticular	Net-like pattern	Livedo reticularis
Scale	Flaky, superficial lesion	Dandruff, psoriasis
Scattered	Randomly distributed lesions	Rubella, roseola
Vesicle	Clear fluid-filled lesion <1 cm	Herpes
Wheal	Swollen, red, raised lesion from edema	Urticaria (hives)

Skin Cancer Assessment – ABCDE Rule

• A – Asymmetry
• B – Border irregularity
• C – Color variation (brown, black, red, white, blue)
• D – Diameter >6mm (pencil eraser size)
• E – Evolving (changing shape, color, or elevation)
• Melanoma: Dark, uneven-textured moles; may itch.
• Acral Lentiginous Melanoma: More common in African Americans and Asians; often appears on palms, soles, or nail beds.
• Subungual Hematoma: Nailbed trauma causes bleeding under nail; may require trephination (drainage).

Pressure Ulcer Staging

Stage	Description
Stage 1	Non-blanchable redness on intact skin
Stage 2	Partial-thickness skin loss; may appear as an intact blister
Stage 3	Full-thickness skin loss, exposing fat; crater-like appearance
Stage 4	Full-thickness tissue loss, exposing muscle, bone, or tendons

Overview of Common Skin Rashes

Condition	Key Features
Impetigo	Golden-yellow crusts on fragile blisters. Intensely itchy.
Measles	Koplik’s spots—tiny white lesions on a reddish base, found inside the cheeks near the molars.
Scabies	Severe nighttime itching. Wavy, thread-like rash found between fingers, around the waist, underarms, and genital area.
Scarlet Fever	Rough, sandpaper-like rash with an accompanying sore throat, commonly caused by Streptococcus bacteria.
Tinea Versicolor	Light-colored, round-to-oval patches mainly on the upper back and shoulders. Typically non-itchy.
Pityriasis Rosea	Rash follows natural skin folds, forming a “Christmas tree” pattern. Starts with a single, larger “herald patch.”
Molluscum Contagiosum	Smooth, dome-like bumps (~5 mm), each with a central dimple and a waxy core.
Erythema Migrans	Expanding, bullseye-shaped red rash with central clearing—an early indicator of Lyme disease.
Meningococcemia	Painful, dark red or purplish skin spots spreading rapidly. Sudden fever, headache, and confusion. Close contacts may need Rifampin prophylaxis.

Topical Steroid Potency & Application

• Ranked from Class 7 (least potent) to Class 1 (most potent)
• Application by Body Area:
  • Non-folded areas (arms, legs, torso): Triamcinolone 0.1%
  • Face & skin folds: Desonide or hydrocortisone
  • Palms & soles: Fluocinolone or clobetasol
• Formulation Absorption & Properties:
  • Lotions < Creams < Gels < Ointments (in increasing order of potency)
  • Creams: Well-absorbed, non-greasy; may sting on broken skin
  • Ointments: Rich in emollients; enhances absorption
  • Lotions: Water-based, spread easily; mildest option
• Absorption Rates by Area:
  • Highest: Face → Next: Underarms & genital region
• General Dosage Guidelines:
  • 2g covers hands, face, head, and anogenital area
  • 3g covers one arm, front or back of the torso
  • 30-60g needed for full-body coverage

Burn Classification & Management

• First-degree burns: Red, blanches with light pressure
• Second-degree burns (partial thickness): Moist, red with peeling edges and scattered blisters (Treat with Silvadene or Polysporin)
• Third-degree burns (full thickness): Thick, pale, or waxy appearance

Referral Criteria:

• Burns on face, hands, feet, genitals, or major joints
• Electrical or lightning-related burns
• Partial-thickness burns covering more than 10% of body surface area (BSA)
• Any full-thickness (third-degree) burn, regardless of age
• Encircling burns (circumferential)

Common Infectious Risks: Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae

Topical Steroid Potency Chart – High Strength

Active Ingredient	Potency	Available Forms & Sizes	Brand Names
Betamethasone Dipropionate 0.05%	100–150× hydrocortisone	Cream/Ointment: 15g, 50g	Diprosone, Beta
		Lotion: 50mL	Betnovate
		Topical Solution: 100mL	Beta
Betamethasone Valerate 0.1%	100–150× hydrocortisone	Cream/Ointment: 15g, 50g	Diprosone, Beta
		Lotion: 50g	Beta
Diflucortolone Valerate 0.1%	100–150× hydrocortisone	Cream/Ointment: 50g	Nerisone
Hydrocortisone Butyrate 0.1%	100–150× hydrocortisone	Lotion: 100mL	Locoid Scalp
		Emulsion: 100mL	Locoid Crelo
		Cream/Ointment: 30g, 100g	Locoid Lipocream, Locoid Ointment
Methylprednisolone Aceponate 0.1%	100–150× hydrocortisone	Not specified
Mometasone Furoate 0.1%	100–150× hydrocortisone	Lotion: 30mL	Elocon
		Cream/Ointment: 15g, 50g	Elocon, Advantan, Advaritan

Skin Conditions

• Fifth Disease – Lace-patterned maculopapular rash
• Varicella, Zoster, Herpes Simplex – Rash with papules, vesicles, and crusts on a red base
• Pityriasis Rosea – Oval, maculopapular lesions with a “herald patch” forming a Christmas tree pattern
• Seborrheic Keratosis – Soft, wart-like lesions on the trunk, varying in color from light brown to black, with a “stuck-on” appearance
• Xanthelasma – Yellowish, raised plaques near the eyelids or brows, often linked to high cholesterol
• Melasma – “Pregnancy mask” appearing as darkened patches on the forehead and upper cheeks
• Vitiligo – Irregular hypopigmented patches on the skin
• Cherry Angioma – Small, bright red papules that blanch under pressure, non-malignant
• Lipoma – Soft, fatty tumors beneath the skin, typically on the neck, trunk, arms, or legs
• Nevi (Moles) – Round, pigmented spots or raised lesions, generally harmless
• Xerosis – Genetically inherited extreme dryness affecting skin, eyes, and mouth
• Acanthosis Nigricans – Velvety, darkened skin thickening, commonly on the neck or armpits, associated with diabetes, obesity, metabolic syndrome, and some cancers
• Acrochordon (Skin Tags) – Soft, flesh-colored, painless skin growths with a pedunculated shape
• Candida Infection – Bright-red rash with satellite lesions, commonly found in moist areas
• Intertrigo – Widespread red rash in skin folds due to bacterial infection
• Acral Lesions – Rashes occurring on extremities

Wound Healing & Treatment

Factors That Slow Healing

• Aging, malnutrition, immune system compromise, limited mobility, chronic stress, diabetes, medications (steroids, anticoagulants), prolonged pressure, smoking, secondary infections

Wound Closure Types

• Primary Healing – Closed within 24 hours using sutures, adhesive strips, or tissue glue
• Secondary Healing – Left open to heal gradually from the inside out
• Tertiary Healing – Heavily contaminated or poorly perfused wounds (e.g., crush injuries) left open initially before closure

Referral Criteria

• Infected wounds, clenched-fist injuries, facial wounds with potential cosmetic concerns, retained foreign objects, joint capsule involvement, electrical or chemical burns, high-pressure injection wounds, suspected child abuse

Wound Care Guidelines

• Avoid suturing wounds older than 24 hours (infection risk increases after 12 hours)
• Tdap booster required if last tetanus shot was over 5 years ago
• Suture Removal Timeline
  • Face: 5–7 days
  • Scalp: 7–10 days
  • Upper limbs: 7–10 days
  • Lower limbs: 10–14 days

Miscellaneous Medical Notes

• Bed Bugs – Cause irritation but do not spread infections
• Squamous Cell Carcinoma (SCC)
  • Common in sun-exposed areas, lower lip frequent in smokers
  • Appears as papules, plaques, nodules, smooth or ulcerated lesions, often bleeds easily
  • Diagnosis confirmed via biopsy or excision
  • “NOSUN” Mnemonic for SCC Features:
    • N – Nodular
    • O – Opaque
    • S – Sun-exposed areas
    • U – Ulcerative
    • N – Non-distinct borders
• Irritant Contact Dermatitis – Triggered by prolonged exposure to water, soaps, detergents, fiberglass, dust, food, cleaning agents, lubricants, petroleum products, solvents, and resins
• Allergic Contact Dermatitis – Caused by allergens such as poison ivy, rubber, nickel, and fragrances

Lichen Planus

• Appearance: Small, flat, reddish-purple bumps with white scaling
• Symptoms: Itching, commonly affecting wrists, forearms, and ankles
• Causes: Associated with Hepatitis C; usually self-resolves

Antibiotic Guide for MRSA (ABCD Mnemonic)

• A – Antibiotics for MRSA
• B – Bactrim
• C – Clindamycin
• D – Doxycycline

Condition	Cause	Symptoms	Diagnosis	Treatment	Key Considerations
Rocky Mountain Spotted Fever	Bite from infected dog or wood tick (Rickettsia rickettsii)	Sudden high fever, chills, severe headache, nausea, vomiting, light sensitivity, muscle pain, joint pain, conjunctivitis. Rash (small red spots) appears 2-5 days later, starting on hands/feet and spreading to the trunk.	Antibody testing for Rickettsia, skin biopsy, bloodwork (CBC, LFTs, CSF analysis).	Doxycycline 100 mg twice daily for 7-14 days. Early treatment is critical—can be fatal if delayed past 8 days. Remove tick carefully by gripping near the skin and pulling steadily upward.	Fatal in 3-9% of cases. Most common in southeastern and south-central U.S. (April-September).
Brown Recluse Spider Bite		Fever, chills, nausea, vomiting. “Red, white, and blue” lesion: central blister with surrounding gray/purple discoloration, encircled by pale skin and redness.		Apply ice immediately. Clean wound, apply antibiotic ointment, elevate affected area, limit movement, take NSAIDs for pain. Prevention: check shoes, boxes, and storage areas before reaching inside.	Found in the Midwest and Southeast U.S. Severe cases may lead to necrosis.
Erythema Migrans (Lyme Disease)	Infection with Borrelia burgdorferi from a deer tick bite	Expanding red rash with a central clearing (“bullseye”), warm to the touch with a rough texture. Flu-like symptoms. Rash appears 7-14 days after bite and resolves on its own.	Enzyme immunoassay (EIA), indirect immunofluorescence assay (IFA).	Early treatment: Doxycycline twice daily for 14-21 days (up to 28 days). Alternatives: Amoxicillin or Ceftin. Avoid doxycycline in children (stains teeth).	Can cause systemic infection, heart block, Bell’s palsy, Guillain-Barré, and chronic joint pain. Common in Northeast U.S.
Meningococcemia	Neisseria meningitidis (Gram-negative bacteria, respiratory transmission)	Sudden sore throat, cough, fever, headache, stiff neck, light sensitivity, altered mental state. Rapid development of petechial or hemorrhagic rash.	Lumbar puncture (CSF analysis), blood/throat cultures, brain imaging (CT/MRI).	Immediate hospitalization. IV Rocephin (2g every 12h) + IV Vancomycin (every 12h). Isolation and supportive care. Preventive treatment for close contacts: Rifampin twice daily for 2 days and meningococcal vaccine.	Life-threatening within 48 hours. High risk for college dorm residents, people with asplenia, sickle cell disease, or HIV.
Varicella / Zoster	Varicella-zoster virus (chickenpox/shingles, spread by inhalation or direct contact)	Chickenpox: Fever, sore throat, fatigue, itchy blisters that start on the head and spread to the trunk (various stages: vesicles, pustules, crusts). Shingles: Painful grouped vesicular rash along a nerve pathway (dermatome). Contagious until lesions crust over.	Viral culture, polymerase chain reaction (PCR) test, Tzanck smear for shingles.	Chickenpox: Acyclovir within 24-48 hours (avoid aspirin & NSAIDs). Shingles: Acyclovir or Valacyclovir for 7-10 days.	Shingles can lead to long-term nerve pain (postherpetic neuralgia). Risk of eye involvement (herpes zoster ophthalmicus) causing vision loss.
Malignant Melanoma	UV exposure, genetic predisposition	Asymmetry, Border irregularity, Color variation (brown, black, red, white, blue), Diameter >6mm, Evolving shape/size. May be itchy.	Skin biopsy (gold standard).	Immediate dermatology referral. Treatment depends on stage: surgical removal, chemotherapy, or immunotherapy.	High risk of spreading (metastasis). More common in fair-skinned individuals, those with frequent sun exposure, or a family history.
Basal Cell Carcinoma	UV exposure, fair skin	Waxy, pearly nodule with well-defined edges. May have small visible blood vessels (telangiectasia). Slow-growing, may ulcerate. “PUT ON” mnemonic: Pearly, Ulcerating, Telangiectasia, On sun-exposed areas, Nodule.	Skin biopsy.	Surgical excision, Mohs micrographic surgery.	Most common skin cancer. Low risk of spreading but can cause severe local tissue damage if untreated.
Actinic Keratosis		Small, rough, scaly patches on sun-exposed areas (face, ears, scalp, hands). Can range from tiny spots to large lesions.	Clinical diagnosis.	5-Fluorouracil (5FU) cream, imiquimod, topical diclofenac gel, liquid nitrogen, laser therapy, or chemical peels. Dermatology referral for biopsy if suspicious.	Considered pre-cancerous. Can develop into squamous cell carcinoma.
Erythema Multiforme (Stevens-Johnson Syndrome)	Severe allergic reaction (NSAIDs, sulfa drugs, anti-epileptics), infections (Herpes simplex, Mycoplasma pneumoniae), malignancies	Sudden eruption of red “target” lesions with blistering and peeling skin. Accompanied by fever, flu-like symptoms 1-3 days before rash appears.			Risk of progression to Toxic Epidermal Necrolysis (TEN), a life-threatening condition if >30% of the skin is affected.

Condition	Cause	Signs & Symptoms	Diagnostic Methods	Treatment Options	Key Considerations
Psoriasis	Genetic predisposition; rapid skin cell turnover	Red, scaly plaques with fine silvery scales, typically on elbows, scalp, knees, and gluteal folds. Nail pitting. Auspitz sign: pinpoint bleeding when scales are removed. Koebner phenomenon: new lesions develop at sites of skin trauma.	Clinical diagnosis	First-line: Medium-strength topical corticosteroids. Second-line: Vitamin D analogs, topical retinoids (tazarotene), coal tar. UVB therapy may help. Caution: Beta-blockers can worsen symptoms.	Can lead to psoriatic arthritis (joint pain, swelling, warmth) and guttate psoriasis (linked to Group A strep infection).
Tinea Versicolor	Fungal infection by Pityrosporum orbiculare or Pityrosporum ovale	Hypopigmented, round macules on the chest, shoulders, and back that become noticeable after tanning. Usually asymptomatic.	KOH prep: Shows “spaghetti & meatballs” pattern (hyphae & spores).	Topical: Selenium sulfide, ketoconazole cream. Oral: Antifungal medications if severe.	Common in warm, humid climates. Can recur despite treatment.
Atopic Dermatitis (Eczema)	Genetic condition causing chronic itchy rash	Location: Hands, flexural folds, neck. Appearance: Itchy, red, round-to-oval plaques that may ooze and later become thickened (lichenified). Exacerbated by stress and environmental factors.	Clinical evaluation	Moisturizers, lukewarm baths, and topical corticosteroids (low to high potency). Oral antihistamines for itching.	Risk of skin fissures and infections. Often part of the “atopic triad” (eczema, allergies, asthma).
Acute Cellulitis	Bacterial infection (Strep pyogenes, Staph aureus including MRSA)	Red, swollen, warm, and tender skin infection with poorly defined edges.	Clinical assessment	Non-purulent: Cephalexin or dicloxacillin. MRSA suspected: Bactrim, doxycycline, or clindamycin. Tetanus booster if >5 years since last dose.	Monitor closely—follow up in 48 hours. Refer if worsening, spreading, or affecting immunocompromised patients. Possible complications: osteomyelitis, sepsis.
Cutaneous Abscess, Furuncle, Carbuncle	Staph aureus (MSSA or MRSA)	Infection of a hair follicle leading to a painful, red lump (abscess). Carbuncle: Cluster of abscesses.	Culture & Sensitivity (C&S)	Incision & drainage (I&D), warm compresses. Antibiotics: Bactrim, doxycycline, or clindamycin. MSSA: Dicloxacillin or cephalexin.	Consider mupirocin (Bactroban) for folliculitis to prevent recurrence.
Erysipelas	Strep pyogenes	Rapid-onset red, swollen, warm skin with sharp borders, commonly on legs or face.	Clinical diagnosis	Mild cases: Keflex or dicloxacillin. Severe cases or immunocompromised patients: Hospitalization for IV antibiotics.	Can spread rapidly. Immediate treatment reduces risk of complications.
Bite Wounds	Animals: Pasteurella multocida (dogs/cats). Humans: Eikenella corrodens. Rabies risk: Skunks, raccoons, foxes, coyotes.	Human bites: Highest infection risk. Cat bites more likely to cause infection than dog bites. Rabies risk with wild animal bites.	Wound culture & sensitivity	First-line: Augmentin for 10 days. PCN allergy: Doxycycline or Bactrim + Flagyl/clindamycin. Rabies protocol: Immune globulin + vaccine if indicated.	Do not suture infected wounds. Follow-up in 24-48 hours. 80% of cat bites become infected.
Hidradenitis Suppurativa	Chronic inflammation of sweat glands (often in axilla, groin)	Painful, deep red nodules under the arms or in the groin that may rupture and form abscesses.	Culture & Sensitivity of drainage	Mild: Chlorhexidine washes, topical clindamycin for 12 weeks. Moderate-severe: Oral tetracyclines, doxycycline, or minocycline.	High recurrence rate. Can lead to scarring and sinus tract formation.
Impetigo	Staph aureus or Strep pyogenes	Non-bullous: Red sores that develop into honey-colored crusts. Bullous: Blisters filled with clear or yellow fluid that rupture, leaving raw skin. Ecthyma: Deep ulcerated form.	Culture & Sensitivity of crusts or lesions	Mild cases: Mupirocin 2% ointment for 10 days. Widespread infection: Cephalexin or dicloxacillin. PCN allergy: Azithromycin or clindamycin.	Highly contagious. No school for 48-72 hours after starting treatment. More common in warm, humid weather.

Condition	Cause	Signs & Symptoms	Diagnostics	Treatment	Key Considerations
Herpetic Whitlow	Herpes simplex virus (HSV-1 or HSV-2)	Painful blisters on the side of the finger or near the cuticle. Often follows direct contact with a cold sore or genital herpes lesion.	Clinical diagnosis	Pain relief with NSAIDs or analgesics. Severe cases: Acyclovir.	Avoid sharing personal items (gloves, towels). Keep lesions covered until fully healed to prevent spread.
Pityriasis Rosea	Unknown (suspected viral origin)	“Herald patch”: single oval lesion with a salmon-colored center and red outer ring on the trunk. Later spreads in a “Christmas tree” pattern along skin lines.	Clinical diagnosis; rule out secondary syphilis if needed.	Self-limiting (6-8 weeks). If itchy: Antihistamines or mild topical steroids.	Benign condition; no treatment needed unless symptomatic.
Scabies	Sarcoptes scabiei (mite infestation)	Intensely itchy rash, worse at night. Common in web spaces of fingers, toes, axillae, waist, groin, buttocks, breasts, and penis. Linear burrows may be visible.	Skin scraping + wet mount: Identifies mites, eggs, or feces under a microscope.	First-line: Permethrin 5% cream (apply to entire body, wash off after 8-12 hours). Household contacts must be treated. Wash clothes and bedding in hot water.	Avoid Lindane (Kwell) due to neurotoxicity risk. Symptoms may persist for weeks after treatment.
Tinea (Ringworm) / Dermatophytosis	Fungal infection	Types: Scalp (tinea capitis), feet (tinea pedis), body (tinea corporis), groin (tinea cruris), hands (tinea manuum), beard (tinea barbae). Presentation: Itchy, red, circular patches with central clearing and raised, scaly edges.	KOH prep: Reveals fungal hyphae and spores.	First-line: OTC antifungal creams (azole-based or terbinafine). Severe cases: Oral antifungals (e.g., griseofulvin—monitor liver function).	Tinea capitis requires oral treatment. Can recur if hygiene measures aren’t followed.
Onychomycosis (Fungal Nail Infection)	Fungal infection (yeast or dermatophytes)	Thickened, yellow, brittle nails. Most commonly affects the great toenail. Onycholysis: Nail separates from the nail bed.	Nail culture or KOH prep	Oral antifungals: Fluconazole (weekly for 2-3 months) or terbinafine (Lamisil). Monitor liver enzymes (LFTs) before and during treatment.	Long treatment duration (months). High recurrence rate.
Acne Vulgaris	Hormonal imbalance, excess oil production, bacterial overgrowth, genetics	Lesion types: Open (blackheads), closed (whiteheads), papules, pustules. Severity: – Mild: < 20 comedones, < 15 inflammatory lesions, < 30 total. – Moderate: 20-100 comedones, 15-50 inflammatory, 30-125 total. – Severe: > 5 cysts, extensive involvement.	Clinical evaluation	Mild: OTC washes (salicylic acid, benzoyl peroxide). Moderate: Topical retinoids, antibiotics (clindamycin, tetracycline). Severe: Oral isotretinoin (Accutane), steroid injections. For hormonal cases: Oral contraceptives (Yaz, Desogen).	Takes 6-8 weeks for noticeable improvement. Tetracyclines stain teeth in children under 13. Accutane is teratogenic—requires two forms of birth control.
Rosacea	Chronic inflammatory skin condition	Redness, flushing, small papules and pustules around the nose, mouth, and chin. Ocular symptoms (dry eyes). More common in individuals with fair skin and light eyes (Celtic background).	Clinical diagnosis	First-line: Lifestyle modifications (avoid triggers: spicy food, alcohol, sunlight). Meds: Metronidazole gel (Metrogel), azelaic acid, or low-dose tetracyclines.	Complications: – Rhinophyma: Thickening of nose tissue. – Ocular rosacea: Involves eyelids and conjunctiva (blepharitis, redness).
Anthrax	Bacillus anthracis (bacterial infection; zoonotic or bioterrorism exposure)	Cutaneous form: Papule enlarges within 24-48 hours, forming a black eschar with surrounding redness and swelling. Pulmonary form: Flu-like symptoms progressing to severe cough, chest pain, hemoptysis, dyspnea, hypoxia, and shock.	Exposure history + bacterial culture. Pulmonary form: Chest X-ray or CT scan may show mediastinal widening.	Cutaneous form: Doxycycline, ciprofloxacin, or levofloxacin (7-10 days). Bioterrorism exposure: Ciprofloxacin 500 mg BID for 60 days.	High mortality rate for pulmonary anthrax. Immediate medical intervention required for suspected exposure.