A 94-year-old woman was referred to a dermatology clinic with a painless, smooth, hard swelling over the proximal interphalangeal joint of her left little finger (figure). The swelling had been present for 20 years. We could see yellow-white material under the skin. The patient had similar changes over the metatarsal joints of her feet, with overlying ulceration. Skin biopsy and aspiration of joint fluid excluded calciphylaxis, and confirmed that the patient had urate deposits (tophi)-ie, gout. Microscopy with polarised light showed negatively birefringent urate crystals. The serum concentration of urate was 530 umol/L (normal concentration 60-360 mumol/L). We prescribed allopurinol. Gout mainly affects men, but this predominance is less pronounced among elderly people-in whom gout usually affects more than one joint, often affects the hand, and tends to develop gradually, with fewer acute attacks than in younger people. Nonetheless, painless gout is rare.
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