Ulcers secondary to gout
Gout is an inflammatory disease characterized by hyperuricemia. Once thought to be rare in Africa, the numbers increase with more Africans adopting a western lifestyle. Given this, there is also a rising incidence of ulcerations due to gout observed on the continent.
When hyperuricemia is poorly controlled by diet or medications, uric acid crystals deposit in joints causing severe inflammation. This is usually associated with severe pain. Sometimes the inflammation causes a skin breakdown over the joint, leading to chronic ulcerations. This is most often seen in the toe areas - especially the interphalangeal joints.
The affected joints are usually visibly inflamed, reddish and warm to the touch, but we rarely see secondary infection. Very often, doctors misdiagnose this and prescribe several courses of antibiotics.
Gout-related ulcers over joints have an opening that goes into the joint. With other types of ulcers, any affection of joints ( for example, arterial - and diabetic ulcers) is seen as something very serious and challenging to treat. Paradoxically, ulcers over gout-affected joints heal surprisingly well if the joint space is rinsed regularly. We have used both saline and antibacterial solutions like super oxidized water to irrigate gout-affected joints and cannot say with certainty that we see any difference in results. A possible argument for using antibacterial solutions is that they may prevent a secondary infection, but this is theoretical. The irrigation aims to dilute the crystals in the joint and try to rinse them out. Often we also have to physically remove crystal lumps with forceps.
The prognosis for gout-related ulcers is surprisingly good, but it takes a very long time for these ulcers to heal - usually at least three months, often longer. This requires patience from both the patient and the caregivers.
The frequency of irrigating the joint is a factor that determines how fast the ulcer will heal - if, for example, the affected joint is rinsed daily, the ulcer will heal quicker. This may be impractical in some situations, but one should at least try to irrigate the joint twice weekly as a rule of thumb.
It is usually not very painful to irrigate the joint as long as this is done gently. We typically use a venflon ( without the needle) to enter the joint area and rinse the joint with slight pressure to force out crystal particles.
It is equally important that the gout disease itself is better controlled - the patient has to receive information on purine-poor diets. In most cases, it will be necessary with medication therapy to keep the uric acids at an optimal level.
If the patient has severe joint pain, Cholchizine or other NSAIDS in combination with paracetamol are used. It may be necessary to supplement with codeine for a few days to get over the worst pain. Only very rarely do stronger analgetics need to be used. Before prescribing NSAIDs, make sure that the patient tolerates these.
It usually takes several months before dietary regulations, and medication therapy has an effect. It is essential to tell this to the patient from the start so that they don't give up halfway through the treatment.
In many countries, patients with gout are diagnosed and treated by rheumatologists. If you have a patient with severe gout and this type of service is available to you, the patient should be referred to a specialist center.
Patients with uncontrolled high uric acid levels in their blood will, over time, develop uric acid crystals in their joints- especially in the toe areas. When joints are affected by this disease, we call the phenomenon podagra. Sometimes you can see whitish prominences under the skin that resemble rice grains- these are called tophi. Sometimes the crystals accumulate into big tumors. When we hear the word "crystal," we usually think of rock hard crystals. This is not the case with uric acid crystals. The contents of these crystal accumulations have the consistency of toothpaste. These crystal accumulations are odorless - if there is a putrid smell coming from these types of ulcers, you have to suspect a secondary infection.
Figure 1 An acute inflammation of the 4th toe due to gout. Note how red and swollen the distal interphalangeal joint is. This is due to inflammation. Remember: this is not an infection. Many of these patients mistakenly are prescribed a course of antibiotics. Note the whitish areas - these are visible uric acid crystals and are called tophi. copyright: Dr. Antonio Versales
The skin over affected joints often becomes thin, and sometimes ulcerations break out over the inflamed, swollen joints. These ulcerations often appear at times when there is an exacerbation of inflammation. As we mentioned earlier, this is very commonly misdiagnosed as an infection. It is actually surprisingly rare that gout ulcers have a secondary infection. It seems like bacteria do not thrive in these concentrations of uric acid crystals. However, it is very understandable that colleagues misdiagnose this as an infection. So how can you differentiate this from infection? Firstly, you have to find out whether the patient really has gout - for this, you need to be able to measure the uric acid levels in a blood sample. If the patient has typical gout-affected joints in other areas, the diagnosis can be made clinically if no blood tests are available. Laboratory parameters like CRP and white-blood-cell count may be moderately elevated with inflammation alone and are not specific to infection. Moreover, look at the whole patient and not just at the hole in the patient. For example, does the patient have a fever, and what is the general condition? If you are unsure whether antibiotics are warranted, you could, for example, ask the patient to come back the next day or after a couple of days. If there is an infection, you will most often see a change for the worse. If there is no infection, the situation probably looks quite the same as the previous visit.
In the course of months/years, gout-affected joints become destructed. This is often clearly visible on plain x-ray films. Not rarely, this is misdiagnosed as infection ( osteomyelitis), leading to even more antibiotics being prescribed to no use. Paradoxically, even severely destructed joints need not be painful in the long run. The joints are usually very painful while the acute inflammation is ongoing. In the course of the disease, the joint inflammation " burns out" over time, leaving behind a destroyed joint that, strangely enough, often is pain-free.
Figure 2 An ulceration over the base joint of the greater toe ( 1st MTP joint) on the medial side. This joint is very often affected by podagra. Note the crystalline deposits which have broken out through the joint capsule and are now visible in the ulcer. Note how inflamed the skin is surrounding the ulcer. However, this is not a bacterial infection, and antibiotics are not indicated here. Instead, we have to try to remove the crystal deposits blocking the ulcer bed. Often this will decrease the inflammation of the skin. You can remove the crystals with forceps or a curette if you are gentle. If this is very painful for the patient, you can inject some lidocaine directly into the crystals' area. Do not inject this into the inflamed skin, as this will be extremely painful for the patient.
Figure 3 Another patient with gout-related ulcerations over the 1st MTP joint. Again, note the whitish crystals which have broken out through the joint capsule and have deposited themselves in the subcutaneous layer. This ulcer will not heal before we have removed these crystals. This may have to be done in several sessions to avoid causing the patient unnecessary pain. You can inject lidocaine directly into the area with the crystals. Use the thinnest needle you have and inject it very slowly to avoid causing unnecessary distress. copyright: Hermann Frieske, Univ. Giessen
Figure 4 A plain x-ray film of the left forefoot is shown in figure 3. Note the extensive destruction of the joint shown with a stipulated line and arrows. If the radiologist is not aware that the patient has gout the diagnosis will be bacterial osteomyelitis! Therefore the radiologist must be supplied with as much information as possible beforehand.copyright: Hermann Frieske, Univ. Giessen
Figure 5 Gout-related ulcerations can develop over any joint affected by hyperuricemia but are most commonly seen in the forefeet. Sometimes patients can develop these ulcers over joints in the fingers. Here the distal interphalangeal joint is affected on the palmar side.
Treatment of gout related ulcers
Joints with ulcerations are usually intensely inflamed, and it can be difficult to rule out infection. There may be greyish secretion resembling pus. Laboratory parameters like CRP and white blood cell count are usually elevated. As we have mentioned several times earlier in this chapter, there is often no bacterial infection. Remember that the crystal accumulations typically have no smell. If there is a putrid smell coming from secretions, you must suspect infection. If you are very unsure whether a bacterial infection is present, you can do a bacterial swab first. It is useless to do a swab from the surface of the ulcer as you obviously will find bacteria there. These are not proof that there is an infection present. To take a relevant swab, you have to first remove some of the crystals in the wound bed, rinse thoroughly with saline and then take the swab. If there is a visible opening into the joint - rinse the joint with saline via a venflon and then take the swab as close to the joint surface as possible, taking care not to contaminate the swab with bacteria from the surrounding skin! Taking a good bacterial swab is a skill! So- if you are very unsure whether there is a bacterial infection going on, you take a good swab and start a course of antibiotics. If the results from the swab come back negative after a few days, you can terminate the antibiotic treatment.
Ulcerations over gout-affected joints tend to heal surprisingly well over time, even though the chronic inflammation may entirely destroy the joints. To get these ulcers to heal, it is essential to rinse out as many of the crystals as possible. As we mentioned earlier, it is often not very painful for the patient to rinse the joint as long as this is done gently. We routinely use a venflon which we gently insert into the joint space and then, with gentle pressure, irrigate with about 5 ml of saline or super oxidized water. If the skin surrounding the ulcer is not too painful, you can place the syringe directly over the hole ( without a venflon) and rinse in this manner. We need to use some pressure to loosen crystals and rinse them out of the joint. Sometimes this is very effective, and you will see a lot of crystals being rinsed out; at other times, you may only see a few small grains of crystals.
Some patients have more pain than others. If you have a patient whose ulcerations are more painful, you can also use Lidocaine to irrigate the joint space. Inject a milliliter or two of Lidocaine via a venflon into the joint space - let it dwell in the joint for about a minute, and then irrigate the joint with the saline.
Note that new crystals will be formed in the course of a few days. So you need not be disappointed if you see a new accumulation of crystals at the next visit- Keep irrigating the joint for a few weeks, and slowly the production of new crystals will diminish. As mentioned before, it is essential that the patient has diet restrictions to low purine foods and will often need medication to optimize blood uric acid levels.
We don't believe that footbaths have any effect here- they are not effective enough at expelling crystals from the joint space compared to irrigation with a venflon.
Especially initially, when there are many crystals in the joint, we also use a curette or fine forceps to "pluck" out crystals from the joint. You need to have sterile tools to do this; otherwise, you can cause a bacterial infection! Again, if this is done very gently, it is not very painful. If the patient feels this is very uncomfortable, you can inject ( without a needle!) about 2 ml of Lidocaine into the joint space and let it dwell for about 5 minutes. If you have 2% lidocaine available, use this- it works quicker and more effectively, but 1% will also do fine.
Figure 6 A patient with an ulcer due to gout on the outer joint of the second toe. The joint is swollen and reddish. There is no apparent need for antibiotics. Instead, we perform irrigation and manual removal of the crystals from the joint ( see figure 7)
Figure 7 Here, we use a curette to carefully remove some crystals from the joint. This patient had very little pain in the joint, and we did not use any lidocaine here. Gout-affected ulcers usually bleed surprisingly well, even in patients with moderate PAD. It seems as if the inflammation leads to an improvement of the local blood supply around the joint area, and this is maybe why these ulcers heal well once the crystals are removed regularly. So be prepared for a bit of bleeding - this is usually a good sign.
Figure 8 Another patient with the same condition. We again used a curette to remove a lot of the crystals and then irrigated the joint with saline twice weekly. You may have to repat the manual removal of crystals at several sessions in the future in addition to the irrigation procedure. This patient had some pain and did a toe block with lidocaine at the base of the toe because we also wanted to make a separate incision ( see figure 9)
Figure 9 This is the same patient as in figure 8. We made a separate incision on the side of the toe over the joint to get more crystals out. We sometimes use this technique - creating an incision to rinse the joint more effectively. These incisions usually heal well, and to date, we have never had a complication with this technique, but if you have a good primary opening to the joint through the ulcer, it is usually not necessary to make a separate incision.
Figure 10 A plain x-ray of the foot of the patient is shown in figures 8/9. The red arrow points to the toe we treated in the previous images. Note how gout has destroyed most of the bone at the end of the toe ( distal phalanx). This is caused by the chronic inflammation caused by the uric acid crystals and is not osteomyelitis. The stipulated red line shows the destruction of the first MTP joint in the same foot due to gout.
The more often you rinse the affected joint/ remove crystals manually, the quicker the ulcer will heal. Under ideal circumstances, this should be done every second day. We often try to train the patient's spouse or other family members to irrigate the joint. We cannot expect anyone who is not a healthcare professional to manually remove crystals with forceps or other tools, but we can teach them how to install saline into the joint. In this way, the patient can avoid costly transport to the clinic. It is important to teach the caregivers to do the procedure in a clean manner - the syringe must be boiled between uses, and the irrigating solution must be saline which has been purchased. We do not recommend installing boiled water into a joint space as this can lead to osteomyelitis! So yes, there are a few logistical hinders here, but it is not impossible to have the patient treated at home and come for regular check-ups at your clinic with a few weeks intervals where you may have to remove more crystals manually.
The joint should be irrigated twice weekly as a general rule of thumb.
There may be some secretion from these ulcers, and sometimes we use a barrier product to prevent unnecessary maceration. You can use zinc paste or other barrier products. When it comes to the choice of dressing, the most important point is to not put any dressings into the hole that leads to the joint! This can block the natural secretion from the ulcer and lead to secondary infection! Furthermore- do not use dressings that breathe poorly as they also can lead to infections. Hydrocolloid dressings, for example, are, according to our experience, contraindicated here. Apart from that, the choice of dressing is not so important. A polyurethane foam dressing is, for example, a good choice here since it is not too occlusive, absorbs quite well, and the cushioning effect can also protect the ulcer and surrounding skin from pressure. This leads us to another point: Make sure that shoewear does not cause mechanical irritation/pressure over the ulcer area, as this can lead to a catastrophe. If needed, use offloading aids such as self-adhering wool felt, for example, to protect the ulcer area. Often the patient has to use shoes without a toecap ( for instance, sandals) until the ulcer has healed.
Figure 11 The result of regularly removing crystals from the palmar side of the third finger for three months. In addition, the patient adhered to a low-purine diet and received medical treatment for his gout condition. The joint is permanently disfigured, but at the point in time in the lower image, the patient had no more pain, and the rest of the ulcer healed fine.
Surgical treatment of gout related ulcers
There is some discussion about how aggressively we should treat ulcers secondary to gout. However, if there is a strong suspicion of infection or significant necrosis, we usually have a low threshold for surgical debridement. Such surgery aims to open and drain the joint from bacteria and crystals. The joint is meticulously cleaned for all crystals ( and bacteria hiding there), and the incision is not closed and has to heal by secondary intention. In the follow-up, you will notice that new crystals are being formed in the joint, and you will have to continue with regular irrigation, as we have described earlier, over many weeks /months before healing can be achieved.
Figure 12 Under a toe block with lidocaine, an incision has been made over the dorsomedial aspect of the toe joint, and the crystal mass is removed. The joint is thoroughly rinsed. In the presence of infection, the incision must never be closed but must heal by secondary intention. image credits: Antonio Versales
We do not recommend a surgical incision as a routine procedure in situations where there is no infection or necrosis. Instead, we advise you to use the standard irrigation method described earlier, accompanied by manual removal of crystals through the ulcer. On occasion, the hole leading to the join is tiny, making irrigation difficult. In such cases, we often make a small incision through the ulcer to achieve a better opening to the joint. This will have to be done in local anesthesia.
Preventing gout ulcers
One of the most important preventive methods is to keep the blood uric acid levels optimized - by dietary measures and medication. Many doctors are not so interested in gout and tend to downplay the disease. Did you know that gout can cause much damage to the body when it is not monitored well? Many caregivers and patients are not aware of this. In diabetes, we are taught to control blood- sugar levels regularly. In patients with gout, we have to monitor the blood uric acid levels regularly! How often these need to be controlled depends on how severely the disease affects the patient. A blood test every three months may be adequate for some patients- in others, a monthly check may be indicated.
The skin over inflamed joints is very sensitive to pressure. Therefore, we must check the patient's shoes to ensure that nothing can cause mechanical irritation over the affected areas. The shoes must be spacious, and if there are ulcerations on the toes, sandals are preferred. Be aware that the straps of the sandals sometimes are placed such that they can press on the toe joints - inform the patient about this. Self-adhesive wool felt like Hapla felt is excellent for protecting affected areas and preventing pressure ulcers from forming at these sites.
Treatment of hyperuricemia in general
As with all aspects of wound care, prevention is better than treatment; it is essential to have well-regulated uric acid blood levels to prevent gout-related ulcerations.
The interventions against hyperuricemia aim to avoid inflammation of the joints and the formation of crystals (tophi). If we manage to keep the blood concentration of uric acid below 360 µmol/l (300 µmol/l if tophi are already present), the patient will notice a significant improvement in joint problems within a few months. Note that adherence to a purine poor diet only will reduce the blood uric acid level by about 15% ( about 60 µmol/l), but with other lifestyle changes, a further reduction can be achieved. In light to moderate cases, dietary and lifestyle changes can be enough to keep the disease under control.
Often medication treatment is also advised to lower the blood uric acid levels sufficiently and keep them more stable. We will discuss the alternative medications at the end of the chapter.
It is essential to give the patient sufficient information about dietary changes. Food products with a moderate purine content can be used in moderate amounts. Peas, beans, cauliflower, and broccoli should be avoided. Red meats and fatty fish contain a lot of purines. Sugar should be avoided and should not be substituted by fructose or artificial sweeteners. Alcohol reduces the excretion of uric acid through the kidneys, and beer significantly increases uric acid levels because it has a high purine content. On the other hand, moderate consumption of wine does not affect uric acid levels as much. Overweight and fasting can both increase uric acid levels, while a slow reduction of weight has positive effects. Low-fat dairy products, sufficient intake of fluids ( especially water), and Vitamin- C supplements can increase the renal excretion of uric acid. So as you will be aware, there are many factors influencing uric acid levels. We advise you to make an information sheet for the patient with written advice as your patient will definitely not remember half of what you told them about gout.
Food and beverages with high purine content
Entrails from animals and fish
Shellfish (shell, shrimps, crabs, roe)
Fatty fish( sardines, herring, mackerel)
Food with moderate purine content
Fish, with exception of the species mentioned above
White meat ( chicken, turkey, crocodile)
Beans, peas, mushrooms, spinach, cauliflower, broccoli, avocado, asparagus
Food with low purine content
Vegetables with the exception of the above, potatoes, fruit, spices
Bread and other corn products
Butter, margarine, oil
Nuts (except for peanuts and cashew nuts)
Medications to treat acute uric acid flares
Figure 13 In the acute phase, the affected joint ( here, the 1st MTP joint of the right foot) is swollen, red, and most often very painful. Remember: this is not a bacterial infection, and antibiotics are not indicated.copyright: Hermann Frieske , Univ. Giessen.
Since this chapter primarily focuses on treating gout-related ulcerations, we will not go into detail about the medications used to manage gout. However, since many doctors are unsure of what to do in an acute gout attack, we will discuss some principles here. In summary, NSAIDs are often used to alleviate some of the acute symptoms of the attack. Remember that gout leads to inflammation of the tissues, so it makes sense to use anti-inflammatory drugs to counteract this process. Previously Cholcicine was routinely used- this is a small-spectrum NSAID, but it has some drawbacks, and primarily other NSAIDs like Voltaren, Ibumetin, or Indometacine are used today. Be aware that NSAIDs interact with several different medications, and many elderly have contraindications against NSAIDS ( chronic heart disease or kidney disease, for example). A study from 2016 by Rainert et al. found that orally administered prednisolone alone gave significantly fewer complications than the NSAID Indometacine. Some authors, therefore, suggest treating acute attacks with, for example, 30mg Prednisolone x 1 for about five days. This can be combined with Paracetamol and NSAIDS if the patient has no contraindications. Salicylic acid should be avoided when possible as this reduces the renal secretion of uric acid. Diuretics of the Thiazide group should also be avoided. Newer anti-inflammatory drugs are being developed that may change the way we treat acute gout flares in the future.
Injections with corticosteroids directly into joints can be used in severe cases. This is a sterile technique as it is of utmost importance not to introduce bacteria and other microorganisms into the joint space. It is easier to inject a joint with a bigger joint like the knee, for example. It may be very difficult to inject into the small joints of the toes and fingers, especially when the joint is deformed and destructed by the disease.
Prednisolone and NSAIDS alleviate the inflammation, but they have no impact on the uric acid themselves. To reduce uric acid levels, medications like Allopurinol and Probenecid are utilized. Note: never start with one of these drugs alone under an acute attack - they will worsen the symptoms initially as they can paradoxically increase the deposit of crystals at the start of the treatment! It is, therefore, usually wise to start the inflammatory treatment with prednisolone/ NSAIDS first for a few days until the inflammation has begun to calm down and only then start the other medications.
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