The Journal of Dermatology

Vol. 28: 433436, 2001

Chronic Tophaceous Gout Presenting as

Hyperpigmented Nodules in the Limbs
of a Patient with Coexisting Psoriasis
Soyun Cho, Gwang-Jin Koh, Jee-Ho Choi, Kyung-Jeh Sung,
Kee-Chan Moon and Jai-Kyoung Koh

Abstract
We describe a 53-year-old male renal transplant recipient with hypertension and triglyc-
eridemia, who showed rare manifestations of gout presenting as brownish nodules on the
arms and legs as well as chronic tophaceous gouty arthritis of the hands and feet mimick-
ing rheumatoid arthritis, in association with subsequently developed psoriasis of the
palms. In elderly Asian men, hypertension and renal insufficiency may be risk factors pre-
disposing to the development of multiple hyperpigmented nodules of tophi in the more
proximal extremities.
Key words: gout; hyperpigmentation; psoriasis

daveric renal transplant 17 years previously for

Introduction
Gout is a metabolic disease resulting from
tissue deposition of monosodium urate crys-
tals from supersaturated extracellular fluids.
The cutaneous manifestations of gout in-
clude acute gouty arthritis and chronic dis-
ease with aggregates of crystals in connec-
tive tissues (tophi) (1). We describe an un-
usual case of tophi occurring in both fore-
arms, thighs, and lower legs as multiple
brownish nodules. In addition, the patient
had a deforming arthritis of the hands and
feet resembling rheumatoid arthritis (RA)
and simultaneous psoriasis.
Case Report
A 53-year-old Korean man had received a ca-
Received March 9, 2001; accepted for publication
May 29, 2001.
Department of Dermatology, Asan Medical Cen-
ter, College of Medicine, University of Ulsan, Seoul,
Korea.
Reprint requests to: Soyun Cho, M.D., Department
of Dermatology, Asan Medical Center, College of
Medicine, University of Ulsan, 388-1 Poongnap-dong,
Songpa-gu, Seoul, 138-736, Korea.
end-stage renal disease secondary to hyperten-
sion. In the family history, his father also had hy-
pertension. Ten years previously, he experi-
enced the first acute attack of gout; since then,
he has been suffering from severely deforming
polyarticular gouty arthritis of the hands and
feet. Seven years previously, brownish subcuta-
neous nodules began to develop on his thighs
and lower legs; 3 years previously, the nodules
also formed on both forearms with gradual in-
creases in their size and number. Three months
before his first visit, scaly red macules and patch-
es began to appear on both palms. His medical
problems included hypertension, azotemia, and
type IV hyperlipidemia. He had been treated at
the department of rheumatology for 4 years with
oral colchicine (0.6 mg daily), allopurinol (300
mg daily in one dose), indomethacin (100 mg
daily in 2 divided doses), lovastatin (40 mg daily
at night), and amlopidine besylate (5 mg daily).
Physical examination revealed multiple, well-
defined, diffuse, nontender, movable, hard, rice-
to large bean-sized, brown nodules on both fore-
arms, thighs and lower legs (Fig. 1a). In addi-
tion, there were tender, enlarged deformities of
the hands, fingers, feet, and toes. On both palms
434 Cho et al
Fig. 1a. Multiple, well-defined, diffuse, non-
tender, movable, hard, rice- to large bean-
sized, brown nodules are present on the fore-
arms.
Fig. 2a. Biopsy specimen from a hyperpig-
mented nodule of the forearm shows multi-
ple, amorphous eosinophilic deposits in the
reticular dermis, surrounded by mononu-
clear cells and multinucleated giant cells (H
& E, 40).
Fig. 1b. On both palms and volar aspects of fin-
gers, well-defined, scaly, round to geographic
red macules and patches are present.
and the volar aspects of the fingers, there were
well-defined, scaly, round to geographic red
macules and patches consistent with psoriasis
(Fig. 1b).
Four years previously, his white blood cell
count was 19,400/mm3, erythrocyte sedimenta-
tion rate 34 mm/hr, serum uric acid 10.4 mg/dl
(normal, 3.07.0), creatinine 1.5 mg/dl (0.7
1.4), and triglyceride 584 mg/dl (0200). Cur-
rent uric acid and triglyceride levels were now
reduced at 7.4 and 287 mg/dl, respectively. His
blood pressure was 140/90 mmHg. Roentgeno-
grams of both feet showed asymmetrical
punched-out bony erosions with sclerotic rims
and overhanging edges, mild soft tissue swelling,
and hallux valgus deformity of metatarsopha-
langeal joints of both great toes. X-rays of both
knees showed bony spurs in the superoinferior
aspect of both patellae and tibial intercondylar
eminences, consistent with osteoarthritis. Chest
X-ray revealed a hypertensive heart configura-
tion.
A punch biopsy specimen from the right fore-
arm revealed multiple, amorphous, eosinophilic
deposits in the reticular dermis, surrounded by
mononuclear cells and multinucleated giant
cells (Fig. 2a). There was an increased content
of epidermal melanin but no melanocytic hyper-
plasia. Melanin pigmentary incontinence and
pigment-laden melanophages were present in
the superficial dermis (Fig. 2b). On polariscopic
 Gout and Psoriasis 435

Fig. 2b. Superficial dermis of the same biopsy showing increased epider-
mal melanin content and melanin pigmentary incontinence with several
melanophages (H & E, 400).

examination, the deposits were composed of
negatively birefringent, needle-shaped monoso-
dium urate crystals. Histopathologic examina-
tion of the palmar scaly lesions showed charac-
teristic features of psoriasis.
The psoriatic lesions have been treated with
calcipotriol cream and topical corticosteroid
with improvement.
Discussion
Metabolic disorders associated with gout
and diseases predisposing to gout include
atherosclerosis, ethanol abuse, hyperlipi-
demia (particularly hypertriglyceridemia),
hypertension, obesity, renal insufficiency,
thiazide diuretics, myeloproliferative disor-
der, and diseases with high tissue nucleic
acid turnover such as psoriasis (1, 2). This
patient had many of the risk factors: hyper-
triglyceridemia, hypertension, renal insuffi-
ciency, and psoriasis. Among the sixteen
previously reported cases of gout coexisting
with psoriasis (36), only three had gout
preceding the onset of psoriasis. In a series
of six patients, the risk factors for gout and
intradermal tophi included renal failure in
all six, hypertension and chronic diuretic
therapy in four, and one patient each with
alcohol abuse, chronic low dose acetylsali-
cylic acid, myeloma, and a positive family
history (7). Our patient has two of those
conditions, renal failure and hypertension.
The natural history of gout involves four
clinical stages (8), the fourth of which is
chronic tophaceous gout. Tophi usually
occur ten or more years after the onset of
gout and are present in less than 10% of af-
fected patients. They appear as firm pink
nodules or fusiform swellings in periarticu-
lar sites about the feet, ankles, knees, and
fingers, in and around bursae, and in the
subcutaneous tissues overlying tendons and
cartilage. The overlying skin may be yellow,
erythematous, or ulcerated (8). Unusual
clinical presentations of tophi include an ul-
cerative fungating mass of the toe (9), bul-
lous tophi of the fingers (10), and nodular
intradermal tophi (7).
In the literature, only one case of tophi
with skin hyperpigmentation has been re-
436 Cho et al
ported. A 38-year-old Vietnamese man (7)
developed multiple, papular, superficial,
whitish-yellow intradermal tophi associated
with patchy brown pigmentation and areas
of scarring with depigmentation, and limit-
ed to the lower extremities. Our patient
(also Asian) is the second case with cuta-
neous hyperpigmentation; however, in this
case, the tophi were located deeper in the
dermis and were present on both upper and
lower limbs without erosion or scarring. The
exact nature of the skin hyperpigmentation
in this patient and its possible association
with intradermal urate crystal deposition
are unclear. It may in part be related to
postinflammatory dermal hyperpigmenta-
tion in a genetically predisposed individual;
intradermal urate crystal deposition and su-
perimposed inflammation might cause ex-
cessive melanin production by overlying
melanocytes with pigmentary incontinence
and increased dermal melanophages (7).
Such inflammation may have been induced
by the urate crystals in the reticular dermis
by friction or artifacts intensified by the
hard materials in the skin, or by other mech-
anisms yet unknown. The deposition of crys-
tals in the superficial dermis in intradermal
tophi is in contrast to the deeper, subcuta-
neous localization of urate crystal deposits
in the usual periarticular tophus (7).
The differential diagnosis of gouty arthri-
tis includes RA, chondrocalcinosis (pseudo-
gout), osteoarthritis, psoriatic arthritis, and
Reiters disease. Gout and RA rarely coexist;
a negative feedback between these two con-
ditions is widely accepted (11). The correct
diagnosis can be reached by the combina-
tion of accurate history taking (family histo-
ry of gout, alcoholism, previous diuretic
therapy and renal stones), clinical features
(subcutaneous tophaceous deposits), and
specific radiological (asymmetrical erosions
with sclerotic margins and overlying edges)
and laboratory findings (hyperuricemia and
hyperuricosuria) (11). Definite diagnosis of
gout depends on the identification of
monosodium urate crystals in the synovial
fluid.
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