Objectives Although systemic lupus erythematosus (SLE) most commonly occurs in reproductive-age women, some are diagnosed after age 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. Methods 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% confidence intervals) of cutaneous manifestations by age. Study heterogeneity was assessed using I2. Results Thirty five studies, representing 11,189 early-onset and 1,727 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). Conclusions 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.

Pulmonary manifestations of SLE were more common in late-onset SLE patients compared to their younger peers, in particular ILD and serositis. Age-related changes of the immune system, tobacco exposure, race, and possible overlap with Sjögren's syndrome should be examined in future studies.

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