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.
1-3
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.
Figure 1
(A-B) Multiple, whitish, milia-like, firm papules over the finger
pads
Figure 2
Multiple, needle-like monosodi - um urate crystals were visible under polarized
light
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.
1-5
Intradermal tophi are
rare skin manifestations of chronic gout that are characterized by multiple, tiny,
superficial, pustule or milia-like, whitish lesions.
3-5
Rarely they appear at
extra-articular sites such as forearms, arms, finger pad, legs, buttock, thigh, penis,
vocal cords, epiglottis, tongue and abdominal wall.
1-3
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.
1,4
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.
1,2,5
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.