GOUT ULCERS | Wounds Africa

Ulcers secondary to gout

Gout is an inflammatory disease characterized by elevated uric acid levels, also known as hyperuricemia. Once thought to be rare in Africa, the numbers have increased with more Africans adopting a Western lifestyle. Given this, there is also a rising incidence of ulcerations due to gout observed on the continent.

Key points

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 breakdown of the skin over the joint, leading to chronic ulcerations. This is most commonly observed in the toe areas, particularly the interphalangeal joints.

The affected joints are usually visibly inflamed, reddish, and warm to the touch; however, secondary infection is rare. 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 joint affection (for example, arterial and diabetic ulcers) is viewed as a serious and challenging condition 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, such as super-oxidized water, to irrigate joints affected by gout. We cannot say with certainty that we have seen 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 remove crystal lumps with forceps physically.

The prognosis for gout-related ulcers is surprisingly good; however, it takes a considerable amount of time for these ulcers to heal, typically at least three months, often longer. This requires patience from both the patient and the caregivers.

The frequency of joint irrigation is a factor that determines how quickly 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 as a general rule of thumb, one should try to irrigate the joint twice a week.

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 crucial that the gout disease itself is better controlled; the patient must receive information on purine-poor diets. In most cases, it will be necessary with medication therapy to keep the uric acid levels 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 more potent analgesics need to be used. Before prescribing NSAIDs, make sure that the patient tolerates them.

It typically takes several months for dietary regulations and medication therapy to take effect. It is essential to inform the patient from the start so that they do not 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.

Background

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, the phenomenon is referred to as 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 are mistakenly prescribed a course of antibiotics. Note the whitish areas - these are visible uric acid crystals, also known as tophi. Copyright: Dr. Antonio Versales

The skin over affected joints often becomes thin, and sometimes ulcerations develop on the inflamed, swollen joints. These ulcerations usually appear during times of inflammation exacerbation. As we mentioned earlier, this condition is often misdiagnosed as an infection. It is surprisingly rare for gout ulcers to develop 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 need to determine whether the patient has gout; for this, you must be able to measure 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, such as CRP and white blood cell count, may be moderately elevated due to 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 is likely to be the same as it was at the previous visit.

Over the course of months or years, gout-affected joints can become severely damaged. This is often clearly visible on plain X-ray films. Not infrequently, this is misdiagnosed as an infection (osteomyelitis), leading to even more antibiotics being prescribed for no apparent use. Paradoxically, even severely destroyed 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 the degree of inflammation surrounding the ulcer. However, this is not a bacterial infection, and antibiotics are not indicated in this case. 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, being 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 need to be done in several sessions to minimize the patient's discomfort. 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 ulcers over the joints in their fingers. Here, the distal interphalangeal joint is affected on the palmar side.

Treatment of gout-related ulcers

Joints with ulcerations are usually intensely inflamed, making it difficult to rule out infection. There may be a greyish exudate resembling pus. Laboratory parameters, such as CRP and white blood cell count, may be elevated solely due to gout inflammation. 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 emanating from secretions, you should suspect an infection. If you are very unsure whether a bacterial infection is present, you can do a bacterial swab first. It is useless to take a swab from the surface of the ulcer, as you will obviously find bacteria there. These are not conclusive evidence that an infection is present. To take a relevant swab, you first have to 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 using a venflon. 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 unsure whether a bacterial infection is present, 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 can cause significant joint damage. 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 apply pressure to loosen the crystals and rinse them out of the joint. Sometimes this is very effective, and you will see many 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.

Please note that new crystals will form over 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 earlier, the patient must adhere to a diet that restricts low-purine foods and may often require 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.

Initially, when there are many crystals in the joint, we also use a curette or fine forceps to gently "pluck" out the crystals. You must use sterile tools to perform this procedure; otherwise, you risk contracting 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 remove some crystals from the joint carefully. 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 appears that the inflammation leads to an improvement in the local blood supply around the joint area, which may be why these ulcers heal well once the crystals are regularly removed. 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 significant amount of the crystals, and then irrigated the joint with saline twice a week. You may have to repeat 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 remove more crystals. 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 experienced a complication with this technique. However, if a good primary opening to the joint is achieved through the ulcer, it is typically not necessary to make a separate incision.

Figure 10. A plain X-ray of the patient's foot is shown in Figures 8 and 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 perform joint irrigation. We cannot expect anyone who is not a healthcare professional to remove crystals with forceps or other tools manually; however, we can teach them how to administer saline into the joint. In this way, the patient can avoid costly transport to the clinic. It is essential to instruct caregivers on performing the procedure in a sterile manner. The syringe must be boiled between uses, and the irrigating solution must be prepared using 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 hurdles here, but it is not impossible to have the patient treated at home and come in 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.

Dressings

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 essential point is not to 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, avoid using dressings that do not breathe well, as they can also lead to infections. Hydrocolloid dressings, for example, are, according to our experience, contraindicated in this situation. Apart from that, the choice of dressing is not so important. A polyurethane foam dressing is, for example, a suitable choice here, as it is not too occlusive, absorbs moisture well, and its cushioning effect can also protect the ulcer and surrounding skin from pressure. This leads us to another point: ensure that shoewear does not cause mechanical irritation or pressure over the ulcer area, as this can lead to a catastrophic outcome. If needed, use offloading aids, such as self-adhering wool felt, to protect the ulcer area. Often, the patient must 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 of bacteria and crystals. The joint is meticulously cleaned to remove all crystals and bacteria hiding there, and the incision is left open to heal by secondary intention. In the follow-up, you will notice that new crystals are forming in the joint, and you will need to continue with regular irrigation, as described earlier, over several weeks or 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 recommend using the standard irrigation method described earlier, accompanied by manual removal of crystals through the ulcer. On occasion, the hole leading to the joint is so small that it makes 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 under local anesthesia.

Preventing gout ulcers

One of the most important preventive measures is to maintain optimized blood uric acid levels through dietary adjustments and medication. Many doctors are not so interested in gout and tend to downplay the disease. Did you know that gout can cause significant damage to the body if not adequately monitored? Many caregivers and patients are not aware of this. In diabetes, we are taught to control blood sugar levels regularly. In patients with gout, it is essential to monitor blood uric acid levels regularly. The frequency at which these need to be controlled depends on the severity of the disease's impact on 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 the inflamed joints is susceptible 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 may be placed in a way that can press on the toe joints; inform the patient about this. Self-adhesive wool felt, similar to 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.

Treatment goals

Interventions against hyperuricemia aim to prevent inflammation of the joints and the formation of crystals (tophi). If we can maintain 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 alone will reduce the blood uric acid level by approximately 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 recommended to lower blood uric acid levels sufficiently and maintain them at a more stable level. 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 high levels of purines. Sugar should be avoided and not replaced with 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 significantly affect uric acid levels. Being overweight and fasting can both increase uric acid levels, while a gradual weight reduction 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. As you are aware, many factors influence uric acid levels. We recommend creating an information sheet for the patient with written advice, as your patient will likely not remember half of what you told them about gout.

Food and beverages with high purine content

Entrails from animals and fish

Red meat

Shellfish (shell, shrimps, crabs, roe)

Fatty fish( sardines, herring, mackerel)

Beer

Food with moderate purine content

Fish, except the species mentioned above

White meat ( chicken, turkey, crocodile)

Beans, peas, mushrooms, spinach, cauliflower, broccoli, avocado, asparagus

Peanuts, cashew nuts

Food with low purine content

Vegetables except the above, potatoes, fruit, and spices

Bread and other corn products

Eggs

Dairy products

Butter, margarine, oil

Nuts (except for peanuts and cashew nuts)

Olives

Coffee/Tea

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 typically 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 ulcers, we will not delve into the details of the medications used to manage gout. However, since many doctors are unsure of how to manage an acute gout attack, we will discuss some key 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 larger joint, such as the knee, for example. It may be challenging to inject into the small joints of the toes and fingers, especially when the joints are deformed and damaged by the disease.

Prednisolone and NSAIDS alleviate the inflammation, but they have no impact on the uric acid itself. To reduce uric acid levels, medications such as allopurinol and Probenecid are used. 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.

References:

Stamp, L. K., & Dalbeth, N. (2019). Prevention and treatment of gout. Nature Reviews Rheumatology. https://doi.org/10.1038/s41584-018-0149-7

Kopke, A., & Greeff, O. B. W. (2015). Hyperuricaemia and gout. South African Family Practice. https://doi.org/10.36303/sagp.2020.3.0014

Doualla, M., Kamdem, F., & Lekpa, F. K. (2017). AB0874 Characteristics of gout in Cameroon, central Africa: a hospital-based study. https://doi.org/10.1136/annrheumdis-2017-eular.6990

Doualla-Bija, M., Lobe Batchama, Y., Moutchia-Suh, J., Ama Moor, V. J., Kamdem, F., Lekpa, F. K., & Luma Namme, H. (2018). Prevalence and characteristics of metabolic syndrome in gout patients in a hospital setting in sub-Saharan Africa. Diabetes and Metabolic Syndrome: Clinical Research and Reviews, 12(6). https://doi.org/10.1016/j.dsx.2018.06.015

Genga, E. K., Oyoo, G. O., & Kalla, A. A. (2021). The management of gout in Africa: challenges and opportunities. Clinical Rheumatology. https://doi.org/10.1007/s10067-020-05401-z

Usenbo, A., Kramer, V., Young, T., & Musekiwa, A. (2015). Prevalence of arthritis in Africa: A systematic review and meta-analysis. PLoS ONE, 10(8). https://doi.org/10.1371/journal.pone.0133858

Treatment goals

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