title: A systematic review and meta-analysis of cutaneous manifestations in late- versus early-onset systemic lupus erythematosus.
abstract: Although systemic lupus erythematosus (SLE) most commonly occurs in reproductive-age women, some are diagnosed after the age of 50. Recognizing that greater than one-third of SLE criteria are cutaneous, we undertook a systematic review and meta-analysis to evaluate differences in cutaneous manifestations in early- and late-onset SLE patients.
  
  
  
  We searched the literature using PubMed, CINAHL, Web of Science, and Cochrane Library. We excluded studies that did not include ACR SLE classification criteria, early-onset controls, that defined late-onset SLE as <50 years of age, or were not written in English. Two authors rated study quality using the Newcastle Ottawa Quality Scale. We used Forest plots to compare odds ratios (95% CI) of cutaneous manifestations by age. Study heterogeneity was assessed using I(2).
  
  
  
  Overall, 35 studies, representing 11,189 early-onset and 1727 late-onset patients with SLE, met eligibility criteria. The female:male ratio was lower in the late-onset group (5:1 versus 8:1). Most cutaneous manifestations were less prevalent in the late-onset group. In particular, malar rash [OR = 0.43 (0.35, 0.52)], photosensitivity [OR = 0.72 (0.59, 0.88)], and livedo reticularis [OR = 0.33 (0.17, 0.64)] were less common in late-onset patients. In contrast, sicca symptoms were more common [OR = 2.45 (1.91, 3.14)]. The mean Newcastle Ottawa Quality Scale score was 6.3 ± 0.5 (scale: 0-9) with high inter-rater reliability for the score (0.96).
  
  
  
  Overall, cutaneous manifestations are less common in late-onset SLE patients, except sicca symptoms. Future studies should investigate etiologies for this phenomenon including roles of immune senescence, environment, gender, and immunogenetics.
authors.affiliation: University of Wisconsin Hospital and Clinics, Madison, WI.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Medlin
authors.affiliation: Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1625 Highland Ave #4132, Madison, WI 53705.
authors.forename: Karen E
authors.initials: KE
authors.lastname: Hansen
authors.affiliation: Department of Dermatology, Medical Associates Clinic, Dubuque, IA.
authors.forename: Sara R
authors.initials: SR
authors.lastname: Fitz
authors.affiliation: Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1625 Highland Ave #4132, Madison, WI 53705.
authors.forename: Christie M
authors.initials: CM
authors.lastname: Bartels
mesh_terms: D017668:Age of Onset; D000505:Alopecia / Q000209:etiology / Q000503:physiopathology; D005076:Exanthema / Q000209:etiology / Q000503:physiopathology*; D005260:Female; D006801:Humans; D000067562:Late Onset Disorders / Q000150:complications / Q000503:physiopathology*; D054068:Livedo Reticularis / Q000209:etiology / Q000503:physiopathology*; D008180:Lupus Erythematosus, Systemic / Q000150:complications / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010787:Photosensitivity Disorders / Q000209:etiology / Q000503:physiopathology*; D011928:Raynaud Disease / Q000209:etiology / Q000503:physiopathology; D012871:Skin Diseases / Q000209:etiology / Q000503:physiopathology; D014657:Vasculitis / Q000209:etiology / Q000503:physiopathology
keywords: Alopecia; Cutaneous; Late onset; Malar rash; Photosensitivity; Raynaud; Sicca; Systemic lupus erythematosus