To editor,
Gout is a common rheumatological disease caused by a disturbance in uric acid metabolism. Tophi develop during most advanced clinical stage of gout, and usually present as firm pink nodules or fusiform swelling, mainly at periarticular sites. However, unusual skin manifestations caused by intradermal and subcutaneous deposition of tophaceous material at locations other than periarticular regions have been reported.11 Braun-Falco M, Hofmann SC. Tophaceous gout in the finger pads. Clin Exp Dermatol. 2010;35:e22-3
2 Kling CW, Helm TN, Narins RB. Photo quiz. Intradermal tophaceous gout. Cutis. 2001;67:196, 205-6.-33 Aguayo RS, Baradad M, Soria X, Abal L, Sanmartín V, Egido R, et al. Unilateral milia-type intradermal tophi associated with underlying urate subcutaneous deposition: an uncommon cutaneous presentation of gout. Clin Exp Dermatol. 2013;38:622-5.
We presented a case of a 65-year-old with 2-years history of multiple, whitish, milia-like, firm papules over the finger pads (Figure 1). The patient had intense alcohol use and up to 3 kg/day meat consumption for 20 years. Laboratory tests showed raised levels of uric acid (10.8 mg/dl; normal range 3.4-7 mg/dl), creatinine and cholesterol. Punch biopsy was performed from a typical papule. On histopathological examination, numerous, parallel-lined, needle-like, brown monosodium urate (MSU) crystals and a deposit of pink amorphous material consisting with MSU were seen in the dermis. These crystals showed negatively birefringent under polarized light (Figure 2). Based on the clinical, histopathological and laboratory findings a diagnosis of intradermal tophaceous gout was made. He was referred to rheumatology for management of gout.
The natural history of gout involves four clinical stages; asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout and chronic tophaceous gout. Some atypical forms of tophaceous gout have been described, including bullous, fungating, ulcerative gout, gouty panniculitis and miliarial gout.11 Braun-Falco M, Hofmann SC. Tophaceous gout in the finger pads. Clin Exp Dermatol. 2010;35:e22-3
2 Kling CW, Helm TN, Narins RB. Photo quiz. Intradermal tophaceous gout. Cutis. 2001;67:196, 205-6.
3 Aguayo RS, Baradad M, Soria X, Abal L, Sanmartín V, Egido R, et al. Unilateral milia-type intradermal tophi associated with underlying urate subcutaneous deposition: an uncommon cutaneous presentation of gout. Clin Exp Dermatol. 2013;38:622-5.
4 Fam AG, Assaad D. Intradermal urate tophi. J Rheumatol. 1997;24:1126-31.-55 Vázquez-Mellado J, Cuan A, Magaña M, Pineda C, Cazarín J, Pacheco-Tena C, et al. Intradermal tophi in gout: a case-control study. J Rheumatol. 1999;26:136-40. Intradermal tophi are rare skin manifestations of chronic gout that are characterized by multiple, tiny, superficial, pustule or milia-like, whitish lesions.33 Aguayo RS, Baradad M, Soria X, Abal L, Sanmartín V, Egido R, et al. Unilateral milia-type intradermal tophi associated with underlying urate subcutaneous deposition: an uncommon cutaneous presentation of gout. Clin Exp Dermatol. 2013;38:622-5.
4 Fam AG, Assaad D. Intradermal urate tophi. J Rheumatol. 1997;24:1126-31.-55 Vázquez-Mellado J, Cuan A, Magaña M, Pineda C, Cazarín J, Pacheco-Tena C, et al. Intradermal tophi in gout: a case-control study. J Rheumatol. 1999;26:136-40. Rarely they appear at extra-articular sites such as forearms, arms, finger pad, legs, buttock, thigh, penis, vocal cords, epiglottis, tongue and abdominal wall.11 Braun-Falco M, Hofmann SC. Tophaceous gout in the finger pads. Clin Exp Dermatol. 2010;35:e22-3
2 Kling CW, Helm TN, Narins RB. Photo quiz. Intradermal tophaceous gout. Cutis. 2001;67:196, 205-6.-33 Aguayo RS, Baradad M, Soria X, Abal L, Sanmartín V, Egido R, et al. Unilateral milia-type intradermal tophi associated with underlying urate subcutaneous deposition: an uncommon cutaneous presentation of gout. Clin Exp Dermatol. 2013;38:622-5. In our patient, the intradermal gout lesions were restricted to the finger pads. Risk factors predisposing to the development of intradermal gout include renal insufficiency, hypertension, long-term use of furocemid and corticosteroids, long-term duration of disease, obesity, and lack of consistent use of urate-lowering therapy.11 Braun-Falco M, Hofmann SC. Tophaceous gout in the finger pads. Clin Exp Dermatol. 2010;35:e22-3,44 Fam AG, Assaad D. Intradermal urate tophi. J Rheumatol. 1997;24:1126-31. The present case had some of this risk factors. The differential diagnosis of intradermal tophi includes xanthoma and calcinosis cutis, which can be easily diagnosed by examining fluid in polarized light or performing biopsy.11 Braun-Falco M, Hofmann SC. Tophaceous gout in the finger pads. Clin Exp Dermatol. 2010;35:e22-3,22 Kling CW, Helm TN, Narins RB. Photo quiz. Intradermal tophaceous gout. Cutis. 2001;67:196, 205-6.,55 Vázquez-Mellado J, Cuan A, Magaña M, Pineda C, Cazarín J, Pacheco-Tena C, et al. Intradermal tophi in gout: a case-control study. J Rheumatol. 1999;26:136-40.
Allopurinol and colchicine have been reported to improve intradermal gout, and our patient was referred to a rheumatologist for management but was lost to follow-up.
In conclusion, the incidence of gout is increasing, possibly due to an aging population and eating habits. This case illustrates the importance of considering a rare cutaneous manifestation of gout.
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Financial Support: None
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Study conducted at the Şişli Hamidiye Etfal Training and Research Hospital, Dermatology Department – Istanbul, Turkey.
References
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1Braun-Falco M, Hofmann SC. Tophaceous gout in the finger pads. Clin Exp Dermatol. 2010;35:e22-3
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2Kling CW, Helm TN, Narins RB. Photo quiz. Intradermal tophaceous gout. Cutis. 2001;67:196, 205-6.
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3Aguayo RS, Baradad M, Soria X, Abal L, Sanmartín V, Egido R, et al. Unilateral milia-type intradermal tophi associated with underlying urate subcutaneous deposition: an uncommon cutaneous presentation of gout. Clin Exp Dermatol. 2013;38:622-5.
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4Fam AG, Assaad D. Intradermal urate tophi. J Rheumatol. 1997;24:1126-31.
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5Vázquez-Mellado J, Cuan A, Magaña M, Pineda C, Cazarín J, Pacheco-Tena C, et al. Intradermal tophi in gout: a case-control study. J Rheumatol. 1999;26:136-40.
Publication Dates
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Publication in this collection
Nov-Dec 2016
History
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Received
16 Feb 2015 -
Accepted
07 Apr 2015