A 64-year-old female patient presented to our outpatient clinic with asymptomatic rash on her both legs since 1 month. She had a history of diabetes mellitus (using insulin, metformin and sitagliptin) and hypertension (using perindopril). She did not define any signs of venous insufficiency or any bleeding disorder. On dermatological examination, red-brown colored nonfading macules were found on both legs (Figure 1). Complete blood cell count, peripheral smear, urine analysis, bleeding time, prothrombin time and activated partial thromboplastin time were in normal limits; bilateral lower extremity arterial and venous Doppler ultrasonography was normal. Owing to the typical purpuric appearance of the lesions, localization of lower extremities and use of angiotensin-converting enzyme inhibitor, punch biopsy was performed with the preliminary diagnosis of pigmented purpuric dermatosis (PPD) with a second prediagnosis of mycosis fungoides (MF). Histopathological examination revealed an infiltrate dominated by CD4 (+) T lymphocytes filled the superficial dermis with mild hyperkeratosis and parakeratosis. In superficial dermis, there is bandlike T lymphocyte infiltration. This infiltrate forms focal epidermotropism and Pautrier microabscesses. These cells show cellular atypia. Infiltrate was positive for CD3, CD4, CD2, CD5 and CD7 immunohistochemically (Figures 2-5). According to the histopathological findings, the patient was diagnosed with MF. Clinical examination was negative for lymphadenopathy. Serum calcium level, liver and kidney function tests, chest X-ray, abdominopelvic and superficial tissue ultrasonography for lymphadenopathy and serum lactate dehydrogenase levels were normal. Systemic involvement is not considered.

condition affects lives, quantifying this burden, and using this information to improve patients' lives on an individual basis. Balance is often mentioned in personal development and well-being circles. The concept and idea of a balanced life should be incorporated into the dermatology practice and discussed with patients. Environment is defined as the circumstances, objects, or conditions by which one is surrounded. The environment plays an important role in the skin's health. Exposures to smoke, pollution, ultraviolet radiation, different temperatures, toxic chemicals, or prolonged/repeated exposure to water are environmental stressors. It is the level of exposure that determines if damage to the organism will result. Diseases such as contact dermatitis, halogen acne, chemical depigmentation, connective tissue diseases, and skin cancer, and so on have the influence of the environment in their etiology. On the other hand, the environment can contribute to the improvement of certain skin conditions. For example, some patients with psoriasis may improve during summertime due to the exposure to ultraviolet ray. It is important to explore and understand the environment surrounding the patient and how this can affect the skin. We should examine the patient as a whole organism, rather than simply a collection of organs. This important and scientific model of diagnosis and treatment called functional medicine better matches the need to improve the management and prevention of chronic diseases.

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Psoriasis is a chronic inflammatory skin disease, which is mainly characterized with erythematous indurated plaques with squams such as many other inflammatory skin diseases. Also different clinical subtypes of psoriasis can show distinctive clinical appearances. As an example, inverse psoriasis does not have squams and resemble erythema intertrigo; or erythrodermic variant cannot be distinguished from other erythroderma causes sometimes. From reasons above, differential diagnosis of psoriasis should be done carefully to manage a chronic and long-term treatment required disease appropriately. Histopathologial examination is gold standard technique for certain diagnosis; however, dermoscope is a noninvasive and easily applicable diagnostic tool with high specificity. In this chapter, we discuss dermoscopic differential diagnosis of psoriasis.

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