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Lupus Across the Lifespan: SLE in Children, Teenagers, Adults and Seniors

How does lupus differ across the lifespan?

There are two ways to think about lupus across the lifespan:

  1. How does the illness differ if its first symptoms appear when a patient is a very young child, versus an adolescent, adult or elderly person?
  2. How does the illness evolve from its early years after onset, compared to its twentieth or fortieth year?

Systemic lupus erythematosus (SLE or "lupus"), as described in medical papers, on the internet, and in public media, generally refers to the disease as seen at its peak onset ages: That is, lupus most often appears when a person is between 15 and 35 years of age – typically with symptoms of arthritis, rash, hair loss, sun sensitivity, and kidney and blood disease. The illness is subtly different when it appears in people of other age groups. (A disease called "neonatal lupus," which affects some newborn infants, is not actually a form of SLE. This is discussed below.)

How does lupus affect young children?

Children who develop lupus before adolescence are often found to have a genetic abnormality that predisposes them to the disease. Otherwise, the symptoms and treatments do not differ significantly from patients of other age groups. In very young children, the disease tends to be a bit be more severe and to have atypical symptoms (such as severely enlarged lymph nodes) as compared to the “classic” lupus symptoms found in older people. Because young children are still growing, the treatments they receive, which usually include high doses of corticosteroids, may lead to short stature. Their schooling and other social and intellectual development may be disrupted, as it would be for any child suffering a serious illness. While about 90% of older lupus patients are female, the percentage of females in very young patients may be closer to 60% or 70% (although this figure is not agreed upon by all clinicians and researchers).

As noted above, childhood lupus should not be confused with the illness known as “neonatal lupus,” which is a separate condition. A small proportion of newborns of mothers who have high titers of anti-Ro/SSA and anti-La/SSB antibodies are susceptible to neonatal lupus. This is not actually a form of systemic lupus erythematosus. Rather, it is brought about by the mother’s antibodies that are passed through the placenta to the child. These vanish in the infant after about six months. About 25% of children of mothers who have high titers of anti-Ro/SSA and/or anti-La/SSB antibodies (but not children of mothers with low titers) will develop a transient rash and/or blood abnormalities that are generally not harmful and that heal on their own. The rash tends to frighten people, but it is not serious. Most of these children need no treatment at all, and they do not develop lupus later in life. A very small percentage of children of mothers with these antibodies develop a serious heart problem, usually of rhythm, which may require a pacemaker. These conditions are almost always identified before birth. Neonatal lupus is not SLE, and it does not become SLE in later life.

How does lupus affect teenagers?

Those who develop lupus during adolescence tend to have the typical characteristics of SLE that begins in adulthood. However, they are somewhat more likely to have severe symptoms, and they are more likely to have complications of kidney disease.

Teens commonly have concerns regarding socialization, body image, psychological state, and competitiveness in athletics and in school. They are also more likely to experiment with alternative treatments and illicit medications than are adults. For these reasons, the particular medications that doctors prescribe to adolescents (and the degree to which patients accept those prescriptions), may differ from prescriptions given to patients of other ages.

How does lupus affect young adults?

Most commonly, SLE develops when a person is a young adult (18 to 35 years old). In addition to the usual features of the illness, there are many other considerations in patients of this age group that will influence a patient’s and doctor’s choices for medical care, including:

  • Contraception – timing pregnancy with a period of low SLE disease activity state; knowing which methods of contraception are safe and effective (some types are dangerous for some SLE patients).
  • Fertility – knowing how different types of treatment have different effects on fertility (for women and men).
  • Childbearing – coordinating lupus care with maternal fetal medicine to minimize pregnancy complications, and balancing the demands of childcare against the need to manage disease.
  • Career – balancing the demands of work against the possible need for accommodations in the workplace in consideration of SLE symptoms. Such accommodations may include being permitted to work from home or have flexible work hours during periods of lupus fatigue.
  • Other life milestones – understanding that marriage, divorce and caring for young children or aging parents can all increase fatigue and reduce your ability to care for yourself.

How does lupus affect older adults?

Illness that begins at a later age tends to be milder and less frequently complicated by kidney problems.

However, the normal problems of aging begin to dominate the conversation regarding appropriate treatment. These include:

  • Osteoarthritis.
  • Diabetes.
  • Hypertension.
  • Common cancers such as that of the breast or prostate (which are no more frequent in lupus patients than in other persons).
  • Socioeconomic issues, such as healthcare costs, careers and retirement, and disability.

How does lupus evolve from its early years versus a decade out or beyond?

The first few years

Early in its course, SLE tends to be dominated by the classic symptoms that bring patients to physicians:

  • Arthritis
  • Rash
  • Fever
  • Kidney disease
  • Neurological disease

Treatment is more likely to be intense (high doses of medication ) and the response rapid.

Ten years out and beyond

After a decade or so, flare-ups (also called "flares") tend to be milder and less common, because they are treated before they get out of control. Some other characteristics are that these patients:

  • Must stay on treatment to maintain control of their chronic disease.
  • Make more considered choices between accepting the side effects of medications versus managing the symptoms of their ongoing illness.

Weight gain, osteoporosis, infertility and, in some cases, decreased renal (kidney) function, may become issues that are different from what doctors call “active” disease. Patients who have had lupus for several decades generally have not suffered severe complications of “active” disease (such as complete kidney failure, stroke, heart failure or amputation). Their problems relate more to long-term side effects of treatment, which may include:

  • Osteoporosis.
  • Avascular necrosis, also known as osteonecrosis or “bone death.”
  • Disability due to muscle, nerve, or bone damage.
  • Atherosclerosis (when fatty deposits called plaque clog your arteries).
  • Diminished renal function.

How does lupus differ from patient to patient?

The above statements are generalizations based on what happens when one examines large populations of patients. More than almost any other illness, lupus is heterogeneous. That is, it is very hard to find two patients who experience the disease in precisely the same way. For this reason, these generalizations do not apply to any one particular individual. If you wish to know what will happen to you or a loved one with lupus, your best answer will come from reviewing the specifics of your case with your doctor. Consider your symptoms, treatment, the duration of both, and your personal hopes and desires. Then you and your doctor can chart the best course for you to achieve your future goals.

Authors

Image - Photo of Michael D. Lockshin, MD
Michael D. Lockshin, MD
Attending Rheumatologist, Hospital for Special Surgery
Director, Barbara Volcker Center for Women and Rheumatic Disease
 

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