Classification criteria have been developed as a means of categorizing patients with systemic lupus erythematosus (SLE) for study purposes. In 2012, the Systemic Lupus International Collaborating Clinics (SLICC) proposed revised classification criteria that were developed to address weaknesses of the 1997 American College of Rheumatology (ACR) classification criteria.1  Classification of SLE by the SLICC criteria requires either that a patient satisfy at least 4 of 17 criteria, including at least 1 of 11 clinical criteria and 1 of 6 immunologic criteria, or that a patient has biopsy-proven nephritis compatible with SLE in the presence of antinuclear antibodies or anti-double-stranded DNA antibodies.

Involvement of the skin and mucous membrane affects more than 80% of patients with systemic lupus erythematosus (SLE).2

The cutaneous manifestations of SLE are present in 4 of the SLICC criteria, including acute cutaneous lupus, chronic cutaneous lupus, nonscarring alopecia, and oral/nasal ulcers. 

Recognizing that many of the SLE diagnostic criteria are cutaneous in origin, Medlin and colleagues at the University of Wisconsin in Madison performed a systematic review and meta-analysis of 35 studies to examine the differences in cutaneous manifestations in early-onset vs late-onset SLE. 2


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Late-onset SLE was defined as onset of SLE at the age of 50 years or older. A total of 11 189 patients included in the meta-analysis had early-onset SLE; 1727 had late-onset SLE.  The study reported that malar rash was 57% less common in patients with late-onset SLE, with an odds ratio (OR) of 0.43 (95% confidence interval [CI], 0.35-0.52; P<.001). These patients were also less likely than patients with early-onset SLE to display Reynaud’s phenomenon (OR 0.84; 95% CI, 0.71-0.99) or to develop alopecia (OR 0.63; 95% CI, 0.48-0.82). Prevalence of mucosal ulceration was similar in early-onset and late-onset cohorts (OR 2.45; 95% CI, 1.91-3.14).

The authors postulate that a decline in immune competence, or immunosenescence, may be contributing to the fewer cutaneous symptoms found in patients with late-onset lupus.

Conclusion and Clinical Applicability

A meta-analysis of patients with SLE has shown that cutaneous manifestations are less common in late-onset SLE.  Healthcare providers should be aware that this subset of patients often do not display the characteristic malar rash associated with SLE. 

References

1.       Petri M, Orbai AM, Alarcón GS, et al. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum. 2012;64:2677-2686.

2.       Patel P, Werth V. Cutaneous lupus erythematosus: a review. Dermatol Clin. 2002;20:373-385.

3.       Medlin JL,  Hansen KE, Fitz SR, et al.  A systematic review and meta-analysis of cutaneous manifestations in late versus early-onset systemic lupus erythematosus. Semin Arthritis Rheum. 2016; DOI: 10.1016/j.semarthrit.2016.01.004.