Gout usually starts with attacks that come and go: a hot, swollen big toe, a week of pain, then nothing for months. For some people it does not stay that way. Over years of high uric acid, crystals build up into firm, chalky lumps called tophi, on the fingers, elbows, ears, or around the feet and knees. They can look alarming and permanent, and many people assume nothing can be done. That is not true: tophi are deposits of urate crystals, and when uric acid is kept low enough for long enough, they shrink and can disappear entirely. This guide explains what tophi are, what they say about your gout, how long they take to go away, the treatments that work when pills are not enough, including Krystexxa, and research for people with gout that is not well controlled.
Gout still flaring, or lumps that will not go away?
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What are tophi?
Tophi are clumps of monosodium urate crystals surrounded by inflammatory tissue. They form when uric acid in the blood stays above the level at which it dissolves, about 6.8 mg/dL, for years, so crystals keep depositing in and around joints and in soft tissue. They are usually painless between attacks but can become inflamed, break through the skin and drain a white, chalky material, damage nearby bone and joint, and limit movement. Gout with tophi is called tophaceous gout or chronic tophaceous gout. Tophi can sometimes be seen and felt, and ultrasound or a special CT scan can find smaller ones that are not visible.
What tophi say about your gout
Tophi are a sign that the total amount of urate stored in your body is high and that treatment, so far, has not lowered uric acid enough or for long enough. That might be because urate lowering medicine was never started, was stopped, was taken at too low a dose, or because the body simply responds poorly to it. Gout is also linked with chronic kidney disease and high blood pressure, which can make uric acid harder to control. Seeing tophi is a good reason to revisit treatment with your doctor rather than accept them.
Our gout treatment guide covers the standard options.
Do tophi go away?
Yes, they can. The principle is simple: keep uric acid well below the level where crystals form, and the existing crystals slowly dissolve back into the blood. American College of Rheumatology guidance is to lower uric acid with daily medicine, most often allopurinol, adjusted until the level stays below 6 mg/dL, a strategy called treat to target. Many specialists aim even lower when tophi are present, because the lower the level, the faster the crystals dissolve. Even so, it takes time, usually many months and often a few years for large tophi, and flares are common in the first months as crystals mobilize, which is why doctors usually add a low dose anti inflammatory medicine at the start. Surgery to remove tophi is reserved for specific problems, such as infection or nerve compression, because tophi return if uric acid stays high.
When pills are not enough: Krystexxa
For people whose gout stays uncontrolled despite adequate oral medicine, there is pegloticase, sold as Krystexxa. It is an enzyme given by intravenous infusion every two weeks that converts uric acid into a substance the kidneys clear easily, lowering levels far below what pills achieve. Since July 2022 it has been given together with weekly methotrexate, which reduces the antibodies that make it stop working: in the trial behind that change, 71 percent of patients on the combination kept uric acid below 6 mg/dL during month 6, compared with 39 percent on pegloticase alone, and among patients with tophi, more than half had at least one tophus disappear completely within a year. It has important limits: infusions happen in a clinic prepared for allergic reactions, it cannot be used by people with G6PD deficiency, and it is a significant commitment. If you have been offered Krystexxa, or your gout is heading that way, research studies of other new treatments are another option worth knowing about, and some are open specifically to people who have not yet had it.
Why people with uncontrolled gout are needed in research
Many people with gout never reach their uric acid target, and treatment options for those who do not are still limited. New treatments are therefore tested in people whose gout is active or poorly controlled: those with recent flare-ups, visible tophi, or a long history of gout. Some studies ask participants to temporarily adjust their current gout medicines, always under the study team's supervision, and some exclude people who have already been treated with pegloticase. People on dialysis, with advanced heart failure, or with liver failure are usually not eligible.
How to find a gout study
AllClinicalTrials.com lists gout studies recruiting across the US, and you can filter by location before applying. Right now that includes three studies for adults whose gout is not well controlled, from recurring flare-ups to chronic gout with tophi, all testing investigational treatments. The application takes about 5 minutes: you answer questions about your diagnosis, flares, and current gout medicines, and if a study near you looks like a match, the research team contacts you. Nothing is decided until you have gone through informed consent, and participation is voluntary at every step. More studies are on our gout clinical trials page.
Three things to have ready: your most recent uric acid level, the gout medicines you take now and have taken before, and how many flare-ups you have had in the past year.
Common questions
What are tophi? Firm lumps of urate crystals that form under the skin and around joints after years of high uric acid. They are a feature of chronic gout and are often painless between attacks, but they can damage joints.
Do tophi go away? Yes, they can shrink and disappear when uric acid is kept below target for long enough, usually many months to a few years. The lower the uric acid, the faster they dissolve.
Are tophi dangerous? They can damage joints and bone, limit movement, break through the skin, or become infected, so they are a sign that treatment needs attention. They are not a cancer and are not contagious.
What is tophaceous gout? Chronic gout in which tophi have formed. It indicates a large store of urate in the body and usually needs more intensive uric acid lowering.
Can tophi be removed surgically? Sometimes, for specific problems such as infection, nerve compression, or a draining tophus, but surgery does not treat the cause, and tophi return if uric acid stays high.
What is Krystexxa? Pegloticase, an enzyme infused every two weeks for gout that oral medicines cannot control. Given with methotrexate since 2022, it brings uric acid down sharply in most patients and can dissolve tophi, but it requires a clinic visit for each infusion and is not suitable for people with G6PD deficiency.
Do gout trial participants get paid? Some studies offer compensation for time and travel, and study related care is typically provided at no cost to participants. Compensation varies by trial and is always described during the informed consent process before you agree to anything.
See Gout clinical trials recruiting now
Browse open studies, filter by location, and apply in about 5 minutes: Gout Clinical Trials.