An Overview of Tophi in Gout

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Tophi are chunks of uric acid (monosodium urate) crystals that accumulate in and around joints and other parts of the body as the result of advanced gout. A tophus around a joint can cause it to become swollen and misshapen and the skin that covers it to become stretched and taut, sometimes to the point of ulceration. Tophi can erode bone and destroy cartilage, leading to chronic inflammation that can be painful and debilitating. A tophus typically is easy to identify with a visual exam, but sometimes imaging or aspiration may be necessary to confirm a diagnosis. Depending on the size and location of a tophus, it can be dissolved with medication that lowers the levels of uric acid in the blood or, if it's very large, surgically removed. Tophi affect 12% to 35% of people with gout.

Symptoms

Symptoms of tophi depend largely on where they're located, the type of tissue affected, and how advanced the tophi are. Most often they affect joints, in particular, the big toe, fingers, and elbows, as well as the knees or wrists, where they appear as hard nodules that cause the joint to be bulbous and disfigured.

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Acute gout
Acute gout tophi. DermNet / CC BY-NC-ND

Other body parts where tophi can develop include the forearms, ears, Achilles tendon, renal pyramid of the kidneys, heart valves, and sclera (white outer layer of the eyeball) .

Initially, they may not cause pain or limit function of joints. But if they become larger, they can cause joint instability, limit range of motion, and erode bone at the joint site.The skin that lies over a tophus often becomes taut and eventually ulcerates, releasing a soft, white material made of hardened uric acid.

The formation of these mineralized masses can also lead to chronic arthritis and joint deformity.

Causes

Tophi generally start to develop in the joints and tissues in the advanced chronic tophaceous stage. This occurs an average of 11.6 years after an initial attack of gout and is characteristic of gout that has gone untreated for long periods of time. Left untreated, high levels of uric acid, known as hyperuricemia, a condition in which levels of uric acid can cause kidney stones and the deterioration of kidney function.

Diagnosis

The gnarled, twisted appearance of tophi on the hands or other parts of the body is typical. Lab tests can confirm a diagnosis: Magnetic resonance imaging (MRI) or computed tomography (CT) scans evaluate larger tophi as well as the extent of bone and cartilage damage to surrounding joints. A CT scan will yield the most detailed and precise images. Tophi can also be aspirated, and the tophaceous material is expressed and analyzed under a microscope to confirm a diagnosis of chronic tophaceous gout.

Treatment

Treating tophi is often part of a comprehensive gout treatment plan, and includes uric acid-reducing medications and lifestyle changes such as weight management and a diet low in foods that contain purines, such as veal, mussels, tuna, bacon, and beer.

Small tophi that aren't painful or limit movement may not have to be removed—your doctor may prescribe drugs or change your diet to shrink them. For larger tophi, surgical excision may be the best course of action to prevent further damage or the loss of range of motion in your joint.

Several drugs have been found effective at lowering levels of uric acid in the blood to 5 milligrams/deciliters (mg/dL), which is the point at which tophi will dissolve. These include Aloprim (allopurinol), Uloric (febuxostat), Krystexxa (pegloticase), and Benemid (probenecid).

With treatment, tophi can be dissolved and will completely disappear over time.

A Word From Verywell

If you have gout, it is important to monitor your uric acid levels regularly—even during periods when you're asymptomatic and between attacks. Understandably, it's easy to stop paying attention when the gout is dormant and you're pain-free. If you manage gout properly at all times, you stand a better chance of successful longterm treatment. You can head off a decreased quality of life that people with tophi often experience because their gout has been untreated for too long. The good news? With treatment, tophi can be dissolved and completely disappear over time.

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