Tophi are lumps that appear on joints affected by gout. They are made up of crystallized uric acid, a substance that is present in abnormally high concentrations in people with gout. A tophus may develop on the finger, toe, ankle, and elbow joints, and on the ears. Generally, multiple small lumps develop, and over time, one or more may grow much larger.
Gout is an inflammatory joint disease that develops as a result of high uric acid levels. This can be caused by a metabolic abnormality that causes the body to make too much uric acid, or prevents the body from excreting uric acid. Diseases, such as renal failure, may also lead to the development of this condition. Alternatively, the disease may be caused by a diet rich in foods that are high in purine, a component of nucleic acids.
Tophi tend to develop after several years of chronic disease. Generally, these lumps grow when gout is untreated for a considerable length of time, or when the condition is not effective at managing uric acid levels. Gout treatments reduce uric acid levels as much as possible, so when the condition is managed effectively, the lumps are an uncommon development.
When they do begin to develop, they may go unnoticed until they begin to protrude above the skin. The lumps often grow into a joint before they begin to protrude. This means that by the time a tophus is noticed, it may have already begun to damage the joint upon which it grows. The lumps grow larger as more uric acid is deposited, and they can become extremely painful, as they may destroy a large amount of the bone and cartilage of the joint. Sometimes, one may break the skin, potentially causing severe infection of the bone or bloodstream.
Smaller tophi can be treated with a regime of gout treatment to manage uric acid levels. Once levels of uric acid in the blood begin to decrease, the lumps gradually dissolve as the crystallized acid is absorbed into the bloodstream. In some cases, however, this treatment will not effectively treat the condition. Surgical removal of the lumps, and repair of joints, may be needed. A large one that has invaded a joint or broken the skin is likely to need surgery.
Surgery to remove a tophus involves the removal of the lump and draining the joint. The procedure may be difficult, especially when the crystals have invaded the joint. In cases where the lump has broken the skin and formed an extensive ulcer, skin grafts may be used to help the wound heal. High uric acid levels must be managed following surgery to prevent these lumps from reforming.