Revisiting Leonine Facies: Toward More Inclusive Differential Diagnoses

Dear Editor, We read with great interest the article by Paul et al.,1 “Leonine Facies in Dermatology,” published in the Resident’s Area. The authors are to be commended for their concise and insightful overview of the diagnostic approach and differential diagnoses associated with leonine facies, an evocative clinical manifestation that spans a diverse spectrum of dermatologic and systemic disorders. Table 1 in their article provides a useful summary of the common causes of leonine facies. However, upon conducting a comprehensive literature review, we identified several additional dermatologic and systemic conditions, that have been documented to exhibit leonine facies as part of their clinical phenotype. These conditions, though less frequently encountered, are nonetheless important to recognize, especially in atypical presentations.Table 1: Causes of leonine facies. (This table is updated version of table in the article- Paul D, Mustari A. Singh S. Leonine facies in dermatology. Indian Dermatol Online J 2025; 16:440-444)We fully acknowledge the limitations of space in a brief educational review such as the one presented. However, in the interest of scholarly discourse and to assist readers—particularly postgraduate trainees—we suggest a more comprehensive version of the differential diagnosis table. This updated table Table 1, compiled from various peer-reviewed sources, includes supplementary conditions associated with leonine facies.2-8 We believe this broader compilation will enhance diagnostic consideration and serve as a more comprehensive reference point in clinical practice. We hope this contribution adds value to the discussion initiated by Paul et al. and helps sharpen the diagnostic acumen of clinicians and trainees alike when faced with this striking clinical sign. Authors’ contributions We confirm that all authors have read and approved the manuscript for submission. All authors meet authorship criteria, and the manuscript represents honest work. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Use of artificial intelligence (AI) The preparation of this manuscript was carried out entirely by the authors without the use of artificial intelligence technologies.