Gout is a metabolic disorder frequently encountered in the daily practice of internal medicine doctors. Unfortunately, this condition is often underestimated by the public. Many patients only seek treatment when their symptoms are already severe, such as severe joint pain, frequent leg swelling, or even the appearance of hard lumps that interfere with daily activities. However, these conditions are preventable if gout is managed early.
Gout occurs due to elevated uric acid levels in the blood (hyperuricemia). Uric acid is the end product of purine metabolism, a substance naturally present in the body and also found in food. When uric acid levels are too high, uric acid crystals can deposit in joints, soft tissues, and even the kidneys, causing inflammation and pain.
Why do feet often swell and hard lumps appear?
One of the hallmarks of uncontrolled gout is attacks of joint pain accompanied by swelling, redness, and a burning sensation. This complaint most often affects several joint areas, such as:
- Toe
- Ankle
- Knee
- Lower legs
In chronic gout, uric acid crystals accumulate and form tophi, hard lumps under the skin. Tophi often appear around joints, earlobes, heels, or on the toes and fingers. These lumps can be hard and painless at first, but over time they can cause pain, limit movement, and even damage the joints.
Furthermore, high uric acid levels can also cause recurring leg swelling, especially when accompanied by impaired kidney function or the use of certain medications. This condition significantly impairs the patient's quality of life.
Tophi is a complication of chronic gout, indicating persistently high uric acid levels in the blood. Here's an easy-to-understand explanation and medical treatment.
What are Tophi in Gout Sufferers?
Tophi are hard lumps formed by the accumulation of uric acid (monosodium urate) crystals in body tissues. Tophi typically appear in people with uncontrolled gout for years, either due to lack of regular treatment, inadequate treatment, or a risky lifestyle.
Clinically, tophi:
- Feels hard, sometimes painless at first
- Yellowish white in color when seen on the surface of the skin
- Can grow slowly
- Becomes painful and inflamed when infection or inflammation occurs
- Can damage joints and surrounding tissue
Frequently Found Tofi Locations
- Big toe and other foot joints
- Ankles and knees
- Fingers and wrists
- Earlobe
- Heel or Achilles tendon
- Elbow (olecranon)
In advanced stages, tophi can cause limited movement, joint deformities, and even open wounds if they penetrate the skin.
Why Do Tofi Form?
Tophi form when uric acid levels in the blood chronically exceed normal limits ( generally >6 mg/dL). Excess uric acid crystals deposit in joints and soft tissues, triggering repeated inflammatory reactions. Over time, these crystals clump together to form hard masses called tophi.
Factors that accelerate the formation of tophi include:
- Untreated gout or irregular treatment
- Long-term consumption of foods high in purines
- Kidney dysfunction
- Alcohol consumption
- Comorbidities such as hypertension and diabetes
- Advanced age and long duration of illness
Is Tofi Dangerous?
Yes. Tofi is not just an aesthetic problem. If not treated properly, tophi can cause:
- Permanent joint damage
- Chronic pain
- Impaired function and daily activities
- Risk of infection if the skin over the tophi breaks
- Significant decline in quality of life
Therefore, tophi are a strong indication that gout must be treated seriously and long-term.
How to Treat Tophi in Gout
Treatment for tophi aims to reduce uric acid levels, prevent tophi enlargement, and improve joint function.
1. Consistently lower uric acid levels
The target uric acid level for patients with tophi is generally <5 mg/dL. To achieve this, the following is required:
- Long-term uric acid-lowering drugs (e.g. xanthine oxidase inhibitors or uricosurics), as indicated
- Compliance with taking medication regularly and continuously
- Periodic laboratory evaluation
It should be emphasized that gout medication is not taken only when there is pain, but as a long-term therapy.
2. Controlling Pain and Inflammation Attacks
When inflammation occurs around the tophi:
- Anti-inflammatory drugs can be given according to the patient's condition.
- Rest the affected joint
- Cold compress to reduce pain and swelling
3. Lifestyle Changes
- Limit foods high in purines (organ meats, red meat, seafood)
- Drink plenty of water
- Maintain ideal body weight
- Avoid alcohol and high fructose sweetened drinks
- Light and regular exercise
4. Surgical Treatment (If Necessary)
Surgical procedures are not routinely performed, but may be considered if:
- Tofi is very large and interferes with function
- Recurrent infections occur
- Causes severe pain or deformity
- Pressing on nerves or surrounding tissue
This action must still be accompanied by optimal uric acid control so that tophi do not reappear.
When Should a Patient See a Doctor?
Immediately consult an internist or rheumatologist if:
- Hard lumps appear around the joints
- Gout pain often recurs
- Joints feel stiff and difficult to move
- The tophi enlarge or change color
- There are wounds or signs of infection
Tophi are a sign of chronic, uncontrolled gout and should not be ignored. With proper treatment, a healthy lifestyle, and regular monitoring, tophi can gradually shrink or even disappear. Early treatment is key to preventing joint damage and long-term complications.
This article was written by Dr. Patriotika Ismail, Sp.PD (Internal Medicine Specialist at EMC Cikarang Hospital).