Tophaceous Gout: Everything You Need To Know

Symptoms, Treatment, Prevention, and More

Medically reviewed by David Ozeri, MD

Tophaceous gout is a severe form of gout. It results when uric acid crystals form, leading to growths called tophi around the joints and tissues affected by gout.

Gout is a type of inflammatory arthritis that affects over 9 million American adults. It results from hyperuricemia (high uric acid levels) in the body. People with chronic gout may develop tophaceous gout because uric acid levels in the blood stay too high, causing more crystals to form around the joints.

Tophaceous gout can affect any joint or soft tissue area in the body. It can be painful and lead to damaged joints and disability. Fortunately, treatments are available to alleviate symptoms, minimize flares or flare-ups (when symptoms are present), and prevent disability.

This article will cover the four stages of gout, symptoms, causes, treatment, and more. 

Tophaceous Gout: The Most Severe Form of Gout

Medical professionals divide gout into four stages or types, which help them predict how the disease may progress over time.

The four stages of gout are:

• Asymptomatic hyperuricemia

• Acute gout

• Intercritical gout

• Chronic tophaceous gout

Asymptomatic Hyperuricemia

Asymptomatic hyperuricemia is the beginning stage of gout. This is when uric acid builds up in the blood.

Uric acid occurs when the body breaks down substances called purines, produced in the body and found in certain foods and drinks. Eating high-purine foods and drinks (red meats, organ meats, seafood, shellfish, and alcohol) can contribute to high uric acid levels.

High levels of uric acid can occur if the body cannot rid itself of uric acid efficiently for various health reasons, including kidney disease, diabetes, an underactive thyroid, and the use of diuretics (water pills).

This early gout stage causes no joint pain, redness, or swelling. Even so, uric acid blood tests will be elevated. Uric acid forms into urate crystals and starts to collect in the joints.

High uric acid levels are not enough to diagnose gout. Many people with hyperuricemia never develop gout. According to a 2021 Biomedicals report, only up to 36% of people with hyperuricemia will go on to develop gout.

Acute Gout

In the acute stage, sudden nighttime attacks called flares (also called attacks or episodes) might occur. Symptoms of a gout flare include pain, redness, and joint swelling. The most commonly affected joints in this acute stage are the big toes, feet, ankles, and knees.

Attacks in this early stage may last a few days and improve. The flare might be accompanied by chills or fever.

Your next attack may not occur for a few months or up to a year. If attacks are not properly managed, they become more severe and frequent and last much longer as time goes on.

Related: Turf Toe vs. Gout: How to Tell the Difference

Intercritical Gout

Up to 75% of people with gout have a second flare within a year of the first flare, but it is possible to go years without another gout attack. The intercritical stage is an asymptomatic stage (producing or showing no symptoms) between gout flares. This is the time to start long-term treatment.

Future gout flares and complications of the condition can be prevented by lowering uric acid levels with medications. You will also need to adjust your diet and make additional lifestyle changes to prevent future flares.

Related: How to Treat a Gout Flare-Up

Chronic Tophaceous Gout

If uric acid levels remain uncontrolled during the early stages, gout may progress and become chronic. Chronic tophaceous gout is characterized by tophi, an accumulation of urate crystals that appear like lumps under the skin.

If tophi develop in the small joints of the fingers, the fingers may experience physical changes and limited movement. Joint damage and deformity will eventually occur if the tophi are in the bone and cartilage. Tophi under the skin can be painful and get infected.

Gout can become chronic (long-lasting), but this might take a decade or longer. Chronicity results from ongoing inflammation and recurrent attacks.

Fortunately, due to effective treatment options, chronic tophaceous gout is rare. But even if gout gets to this point, uric acid–lowering drugs can reduce your risk for complications and visible tophi.

Related: An Overview of Tophi in Gout

Tophaceous Gout Symptoms

Gout causes inflammation in and around the joints and the soft tissues near affected joints.

Inflammation leads to:

• Severe pain

• Swelling

• Warmth

• Tenderness

• Redness of the skin in the affected joint area

Chronic gout can lead to additional symptoms and problems. These include:

• Synovitis (inflammation of the joint lining)

• Bony erosions (loss of bone)

• Cartilage damage

• Tophi formation

Gout alternates between periods of flare-ups, when symptoms are present and periods, of remission without symptoms. When you get a gout flare, it typically comes on suddenly (usually at night) and quickly worsens. It may take days or weeks to fully recover from a flare.

Chronic gout causes masses of uric acid (tophi) to form under the skin. The number of tophi present will vary based on location, size, and number.

Symptoms associated with tophi include:

• Joint or tissue damage, which can sometimes be visible and other times only seen on imaging

• Stiffness and reduced range of motion in the affected joint

• Disability or decreased ability to use the joint

• Nerve pain due to nerve compression or entrapment

Tophi can cause severe damage to joint and bone tissue. Joint swelling and nerve compression can also lead to breakage and drainage of uric acid crystals, which lead to infection in the affected joint or tissue area.

What Causes Tophaceous Gout?

Gout occurs when uric acid levels in the blood are too high. Typically, the kidneys flush out uric acid through urine excretion. But sometimes, there is too much for the kidneys to filter out, and the excess uric acid builds up in the bloodstream.

When uric acid levels are high, some uric acid can be deposited as urate crystals in the joints. Your immune system will see urate crystals as foreign substances and activate an inflammatory response, which leads to swelling, pain, and other gout symptoms.

Some people are at a higher risk of developing gout due to risk factors that are either non-modifiable or modifiable.

Non-Modifiable vs. Modifiable Risk Factors

Non-modifiable risk factors, such as age, sex, family history, and ethnicity, cannot be changed to affect the possibility of developing a health condition, while modifiable ones can. Diet, smoking status, weight, and a sedentary lifestyle are examples of modifiable risk factors.

Non-modifiable risk factors for gout include:

• Sex: People assigned male at birth are more likely to develop gout than people assigned female at birth.

• Age: Increasing age is strongly associated with an increased risk for hyperuricemia and gout.

• Family history: Having family members with gout means your risk for the condition is higher than that of the general population.

Modifiable risk factors related to gout include:

• Alcohol: Consuming too much alcohol can increase uric acid levels in the blood.

• Diet: Eating many foods and drinks rich in purines (i.e., organ meats, seafood, etc.) or sugar (sweetened beverages) can increase uric acid levels.

• Medical conditions: High blood pressure, kidney diseases, diabetes, and anemia can increase uric acid levels in the blood. If you can manage these conditions, you might be able to reduce your gout risk.

• Medications: Many common medications can increase uric acid levels, including diuretics, beta-blockers (used to treat blood pressure), cyclosporine (an immunosuppressant), and aspirin. If you are at a higher risk for gout, your healthcare provider can switch out these medications for less risky options.

You may develop chronic tophaceous gout if your gout is untreated or not adequately managed. You might also be at risk if you have frequent and severe flares.

Getting frequent flares indicates that your uric acid levels are too high. You can reduce your risk for tophi by following your healthcare provider’s instructions, watching your diet, and taking your medications as prescribed.

Diagnosis

A joint aspiration test can confirm a diagnosis of gout. In this test, the clinician uses a needle to draw synovial fluid or a sample of the tophus deposit, which is then sent to a lab for examination.

Serum uric acid concentrations may support a diagnosis of gout, but hyperuricemia alone does not necessarily mean you have gout. The best time to confirm a diagnosis is during a gout attack. Microscopic examination of tophi deposits can confirm a diagnosis of chronic tophaceous gout.

Additional tests to confirm or rule out gout might include:

• Blood work: Your healthcare provider may recommend a uric acid blood test to measure uric acid levels in the blood. Other blood tests might be done to look for other markers indicating other types of arthritis.

• Imaging: X-rays can be helpful to rule out other causes of joint inflammation. Ultrasound scans can look for urate crystals in joints or tophi masses. A dual-energy computerized tomography (DECT) scan can take images from different views to visualize urate crystals in the joints and tophi masses.

How Is Tophaceous Gout Treated?

There is no cure for tophaceous gout, but the condition is manageable and treatable. It can be treated with medications, lifestyle modifications, and surgery as a last resort.

Medications

Medications to lower uric acid are recommended for the following people:

• Those who experience two or more gout flare-ups per year

• Those who have joint damage visible on imaging

• Those who have tophaceous gout

The American College of Rheumatology recommends starting these medicines during an acute flare rather than waiting until a flare has passed.

Uric acid–lowering medicines used in the treatment of gout include:

• Allopurinol to prevent increased uric acid levels

• Uloric (febuxostat) to reduce uric acid formation

• Probenecid to increase the filtering of uric acid by the kidneys

• Krystexxa (pegloticase), an intravenous medication that breaks down urate crystals

During flares, you can take over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) to reduce gout symptoms and reduce pain. Your healthcare provider can also prescribe additional medicines to treat flares. These may include:

• Colcrys (colchicine) to treat and prevent gout flares

• Prescription NSAIDs like Indocin (indomethacin) to reduce pain and bring down inflammation

• Interleukin-1 blockers reduce the processes that lead to inflammation

• Oral or injectable corticosteroids to bring down inflammation during a gout flare-up

Lifestyle and Self-Care

Some lifestyle changes and self-care strategies may reduce tophaceous gout symptoms and prevent flare-ups, including:

• Diet: People with gout should avoid foods and beverages high in purines. Some foods might be beneficial for reducing gout flares, including low-fat dairy products, citrus foods, and other foods rich in vitamin C.

• Use cold therapy: Try applying ice packs or cold compresses to the gout-affected joint to relieve inflammation and pain. You can apply ice for up to 20 minutes several times a day.

• Rest the affected joints: You should rest a gout-affected joint while managing a flare. If possible, use a pillow to elevate the affected joint.

• Drink water: If you do not get enough water, your uric acid levels may increase. Stay hydrated to bring levels down and reduce recovery time.

Surgery

Surgery may be needed to treat tophaceous gout. This might be the case if tophi masses become infected, compress nerves, or cause damage or severe pain. You may need surgery to remove large or very painful tophi or repair damage from tophi. Most people will never need surgery to treat gout.

Related: How to Remove Gout Crystals From the Joint

How to Prevent Tophaceous Gout

Gout progression can be prevented by starting and staying on top of treatments. Make sure you are following your healthcare provider’s advice and treatment instructions.

If you are overweight, losing weight may reduce your uric acid levels and your risk for future gout attacks. It can also relieve pressure on painful joints.

Physical activity can reduce pain and the potential for disability from gout. Low-to-moderate physical activity has been found to reduce uric levels. Aim for 150 minutes per week of moderate-intensity activity. Consider activities that are easy on the joints, such as walking and swimming.

You should eat a healthy diet, stay hydrated, and avoid foods high in purines. You should also limit alcohol and not smoke. While smoking doesn’t directly cause gout, research has found that cigarettes can increase uric acid levels, which can increase your risk for gout flares and complications like tophi.

Related: How to Prevent Gout

Summary

Tophaceous gout is the most severe form of gout. Urate crystals develop into lumps called tophi, which form under the skin over joints and nearby tissues. Tophi can be painful and lead to joint lining inflammation, bone loss, and cartilage damage.

While there is no cure for gout, it can be managed, and complications can be prevented by using uric acid-lowering drugs and making lifestyle modifications, including diet changes, reducing excess weight, and being active. Making these changes can help prevent gout from becoming chronic and the formation of tophi.

Gout progression can be prevented and does not have to become chronic or cause tophi. Tell your healthcare provider if you experience more than two gout attacks a year, if gout attacks are severe, or if you notice lumps under your skin. Once tophaceous gout is identified, you can start treatments to get uric acid levels under control.

Read the original article on Verywell Health.