It Begins with A Tiny Little Soft Lump 

As mentioned in my book – Gout Demystified, under the Chapter Gout Black Box, it is very hard to predict the direction or pathogenesis of hyperuricemia. Hyperuricemia is when a person is having too much of uric acid in the body, when the concentration of uric acid reached the saturation level, crystallisation happens and form the monosodium urate crystals. 

If the urate crystals are formed within the synovial fluid of the joint, it will cause inflammation that is commonly known as “gout attack”, but it is possible that the urate crystals form somewhere else such as underneath the skin or muscle layers. Usually, tophus tend to form right underneath the skin layers. The logic is very simple, skin has lower temperature which increases the rate of crystallisation. It begins will a tiny needle-like uric acid crystal (which I call it as crystal seed), and as more and more uric acid supplied to the area, the seed crystal attracts even more uric acid deposits around it and gradually form a larger sand-like structure. 

It Was Not Painful At the Beginning…

A person can go through this formation to tophi (means a lot of tophus) without any pain or inflammation. Well, this could be due to the fact that  the white blood cells around skin are not as sensitive than those in the synovial fluids of the joint. Since there’s no pain, people usually do not notice it or just ignore it. The crystallisation process can happen simultaneously beginning with multiple seed crystals and proliferate to a bunch of sand like texture underneath the skin, at this stage, the soft lump is visible and palpable. 

Nightmare Begins When You Start to Feel The Pain…

Tophaceous gout formation can takes up to years until it becomes notorious.As the urate sands begin to bound together and form a larger urate stone (tophus), it becomes harder and larger. Over time, the gouty tophi grow in size and numbers. Depending on the location of the tophi, if it around to joint, it will limits the flexibility to bend and generally all large tophi attract unwelcome attentions. When you begin to feel pain from the gouty tophi, it means some nerves or blood vessels is trapped in between the tophi and it constantly stimulate pain sensation at certain positions. 

Gout Flares + Gouty Tophi = Tophaceous Gout

That is the answer to what is tophaceous gout, it is a condition when gouty inflammation happens around the area which rich gouty tophi deposits. As mentioned before, tophus on the skin surface usually doesn’t trigger the immune system to launch attack. Thinks become complicated when monosodium urate crystals within a joint kicks start the chemotaxis that attract a lot of neutrophils and macrophages to the site of inflammation. When these white blood cells noticed the existence of a lot of gouty tophi sands or stones, they further send out more cytokines to attract even more white blood cells to the area. This cascade of immune reactions worsens the gouty inflammation and make the situation becomes transform from auto-immunity to infection. Depending on the level of the infection, a patient may need to amputate the affected joint due to extreme progression of tophaceous gout, as shown in the following clinical case study: Bilateral First-Ray Amputation of the Foot Due to Severe Tophaceous Gout Complicated by Infection and Discharged Sinus 

Full Report of this case study can be found at: Journal of the American Podiatric Medical Association January 2018, Vol. 108, No. 1, pp. 58-62

Do Not Delay Until Then!

As soon as you noticed abnormal formation of lumps on the skin surface, it is better seek professional medical consultation. The only way to prevent the tophaceous gout situation from getting worse is to make the efforts to bring down the uric acid level.