Tophaceous gout – from toes to tophi. The possible long term outcome of treatment failure

This page was last reviewed on 20 August 2010

Tophaceous gout has fascinated and repelled throughout history. But there wasn't a treatment for it until 1951 when the urosuric drug probenecid was introduced. Other words used to describe it, are tophi (plural) and tophus (singular).

WHAT IS TOPHACEOUS GOUT?

Tophi are the accumulation of the MSU crystals which themselves (usually but not always) form when the concentration of uric acid in serum (blood) increases. The basic process is: serum uric acid increases. i.e. the mg/dL(mmol/µmol) figure rises – MSU (monosodium urate) crystals begin to form – MSU crystals grow into tophi. They appear to the naked eye as knobbly shaped chalky-like lumps. A first appearance in the ears is quite common.

Gout attacks very frequently begin in one of the big toes. But gout tophi usually appear after several years of gout attacks, so you have plenty of time before they appear. About a third of gout sufferers will have a tophus within five years of a first attack. After ten years about half, and after 20 years about three quarters. And so they don't invariably appear in long term gout sufferers. Overall about 25% of gout sufferers have tophi to some degree. As you can see from the above numbers, they are likely to appear in the elderly. The elderly may have a real problem with dealing with tophus or tophi, if drugs such as allopurinol, febuxostat and the uricosuric drugs cannot be used.

Tophi can grow in two ways. They can grow from the original location thus causing joint and nearby bone damage. And they may appear in new body locations and in cartilage, tissues and tendons. And of course they are the reason for the unsightly skin bulging deformities which along with the swollen purple-red toe are gout's most vivid images. Note that tophi grow into bones as well as on them.

It seems that tophi are more likely to appear in the colder parts of the body, those areas furthest from the heart, which are also area where blood circulation is slower. Hence one of their favourite spots are the toes. And their appearance in places like the ear's ridges.

The basic treatment for tophi is to get uric acid levels down to 6 mg/dL and hope that they will begin to dissolve. Studies have shown that this often happens at this 6 mg/dL, or below, level.

DANGERS OF TOPHI GOUT

Take note of what might happen eventually – the stage of gout's development called chronic tophaceous gout. Many people give up

on gout treatment when drug medications and natural remedies do not appear to be working for them. Or they give up because of difficulties dealing with the drugs. And because many treat gout casually thinking something like "well, I only get one or two attacks a year and I can live with that."

Tophi may not be benign.

You must assume they won't be. They can grow, for example, in a joint and in the bone to destroy the joint. This leads to less mobility – the use of feet, elbows, hands, knees – and perhaps joint pain unrelated to gout attack pain. You could end up getting an artificial joint.

They can become ulcerated and septic. If they become septic this condition can lead to sepsis (septicemia) – a bacterial infection in the blood – which is serious and life threatening, and must be dealt with immediately. Doctors will check that the tophus affected area is not septic.

They can exude pus and burst. The result of bursting is their chalky-crystal mass appearing out of and onto the skin.

SURGERY

If drugs don't work there is another way of dealing with tophaceous gout, especially when tophi cause the problems noted above… surgery to remove them. Surgery for tophus or tophi removal may not be available in your country. If this is relevant to you find out if it is.

NATURAL GOUT REMEDIES AND TOPHI

It is highly unlikely that any of the natural gout remedies can deal with tophaceous gout, nor the various gout diets. We have never read an account of this occurring. But some can be of assistance. Diets such as a low purine diet and the Zone diet can help because they can reduce uric acid levels. Drinking lots of water is always de rigueur (because it dilutes uric acid). Alkaline water and other alkalizing agents help too (because they make water more soluble or alkalize the urine).

Always discuss using natural remedies with your doctor, if you consider using them in combination with tophi lowering drug medications that can be used in tophi reduction such as allopurinol and febuxostat.

The good news is that pharmaceutical companies have drug medications under development and in trials, which can deal better with tophi, than ever before in the history of gout treatment. One, febuxostat is approved in countries that are members of the European Union and the U.S. (EU brand name Adenuric, US brand name Uloric). Find out if, or when, it has been approved in your own country if you live elsewhere. Another, Krystexxa may be approved by the U.S. FDA in September 2010.

Now read about the effectiveness of drug medications, including new ones, in tophaceous gout treatment. Click on the links below:

You can read about Febuxostat and Allopurinol and tophi here.

The new gout drug Pegloticase (Krystexxa) is not yet approved anywhere, but it may be in September 2010 in the US. (And other countries later). It offers hope in tophaceous gout treatment. You can read more about Pegloticase here.

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