Intradermal Urate Tophi

Report of 6 Cases

I- Shu Chen Hung-Wen Kuo Ji-Chen Ho

Intradermal urate tophi are rare skin manifestations of chronic gout. They appear as small, super-
ficial, pustule-like, whitish lesions. Histologic features show multiple, intradermal foci of amorphous
deposits surrounded by mononuclear cells and multinucleated giant cells. Renal insufficiency, hyper-
tension, and chronic glucocorticoid use may be associated with the development of intradermal tophi.
The occurrence of intradermal tophi appears to correlate with advanced disease. We report on 6 cases
of intradermal tophi and review the literature on this disorder, which includes a rare case of combined
psoriasis and intradermal tophi. (Dermatol Sinica 21 : 146-152, 2003)

Key words: Intradermal urate tophi, Tophi, Psoriasis, Gout

( 21 : 146 - 152,
2003)

(tophi)
( monosodium urate, MSU )

From the Department of Dermatology, Chang Gung Memorial Hospital-Kaohsiung

Accepted for publication: September 30, 2002
Reprint requests: I-Shu Chen, Department of Dermatology, Chang Gung Memorial Hospital-Kaohsiung, Kaohsiung, Taiwan, R.O.C.
TEL: 886-7-7317123 ext. 2424 FAX: 886-7-7317123 ext. 2421

146


Table I. Clinical data for 6 patients with gout and intradermal tophi
Case 1 Case 2 Case 3 Case 4 Case 5 Case 6
Age (yrs)/sex 46/M 50/M 61/M 47/M 60/F 51/M
Duration of gout (yrs) 10+ 9 20+ 14+ 3 10+
Subcutaneous tophi
(number) Several - Several Several Several Several
Intradermal tophi
Number Several Several Several Several Several Several
Site Legs, Trunk, Legs, arms Legs Legs, Legs, arms
forearms forearms, forearms forearms
Biochemistry
Serum urate (mg/dl) 11.0 10.8 11.5 11.5 9.1 14.2
Serum
Creatinine (mg/dl) 3.5 0.9 4.1 1.3 1.4 1.5
Risk factor
Renal failure + - + + + +
Hypertension + + + + + +
Alcohol use + + - + - -
Cushing syndrome + + + - + +
Hyperlipidemia + + - + + +
Diabetes mellitus + + - + - +
Treatment
Allopurinol + + + + + +
Prednisolone + + + - + +
NSAID + - + + - -
Associated disease - Psoriasis - - - -

6


( Table. I )
1
46 ( Fig. 2a,
2b ) 18

1.5 mm

Allopurinol, ( compensated
colchicine, acetaminophan, prednisolone, polarised light microscope )
indomethacin 78 ( negative birefrin-
1- 2 mm gence ) ( Fig. 2c )
( Fig. 1a, 1b )

Dermatol Sinica, June 2003 147



Fig. 1
1a, 1b Intradermal urate tophi manifesting
whitish pustule-like papules with erythematous
base on both legs .1c, 1d. Psoriatic patient with
intradermal tophi. (1c, erythematous scaling
plaques on the abdomen. 1d, intradermal tophi
on the upper limb)

2
50 81
polytar
liquid ( UVA, UVB )
85

Allopurinol, colchicine
cortisone 89

( Fig. 1c, 1d )

148 Dermatol Sinica, June 2003



Fig. 2
2a, 2b. Multiple foci of amorphous
eosinophilic deposits with feathering
cleft surrounded by dense mononuclear
cells and multinucleated giant cells at the
periphery. (H & E stain, a, 40x; b,100X).
2c, MSU crystals manifesting negatively
birefringent, needle shape (Compensated
polarized microscopy, 50X)

3 4
61 20 47 14
10 Allopurinol, colchicine
NSAIDs




5
60 3

Dermatol Sinica, June 2003 149



urate crystal deposits )

( subcutaneous urate tophi )



6 1 - 4 mm 1
51
88 14


5
Allopurinol, colchicine, acetaminophan, pred-
nisolone, indomethacin

5, 14

20 % 40 %
1

2 ( fungating ) 3

( advanced disease ) 5

Fam 5 1997 6

1, 5
( 6 ) ( 4 )

node ( Heberden's node ) ( 4 ) 3

( aryteoid car- Fam

tiliage )

6 - 13
1997

Fam 1999 Vazquez-

5
" Mellado 14

" ( superficial, intradermal tophaceous 21

150 Dermatol Sinica, June 2003



xanthine oxidase
xan-
42 thine oxidase Brenner 17


Goldman 18 146
( p < 0.05 ) 6 162
( 6 ) ( 4 ) ( 5 )
( Cushing syndrome ) ( 5 ) Munro
NSAIDs ( 3 ) ( Munro microabscesses )
Goldman Constritor
Vazquez - Mellado Fam constrictor 12


Allopurinol

Goldman
( purine )


"
"
Vazquez-
Mellado
14

( )
( )
( 11.9 12.5 4.5
7.9 ) -




( hyperurecemia )
( turnover rate ) 15

Kizaki 14 xanthine
16
( 1 2
oxidase xanthine )

Dermatol Sinica, June 2003 151



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9. Gawoski JM, Balogh K, Landis WJ: Aortic
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fraction of urate and calcium phosphates. J
Clin Patho 38: 873-876, 1985.

10. Ferry AP, Safir A, Melikian HE: Ocular

abnormalities in patients with gout. Ann
Ophthalmol 17: 362-365, 1985.
11. Martinez-Cordero E, Barreira-Mercado E,

Katona G: Eye tophi deposition in gout. J

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152 Dermatol Sinica, June 2003