What is Gout and What Causes It? A Comprehensive Overview

Posted by Alerna Kidney Health on

  • Gout primarily affects the big toe but can also occur in other joints.
  • Recognizing symptoms, distinguishing gout from other forms of arthritis, and understanding triggers are crucial.
  • The most common symptoms of gout include gout pain, swelling, limited range of motion, warmth, and fever.
  • Gout flares can vary in duration, and prompt treatment is essential. Lifestyle modifications, medications, and regular monitoring play vital roles in managing gout.
  • Risk factors include genetics, diet, obesity, and medical conditions.
  • Understanding the disease and its triggers and seeking medical advice when needed is essential for gout management and prevention.

Gout, a condition known for its excruciating joint pain, primarily affects the big toe but can also occur in other joints. In this comprehensive guide, we will delve into what gout is, its symptoms, causes, and available treatment options.

Whether you are experiencing gout symptoms or simply seeking to understand this condition better, read on to find valuable information.

What is Gout?

Gout is a complex form of inflammatory arthritis characterized by sudden and intense joint pain, redness, swelling, and warmth. It typically affects one joint at a time, often starting in the big toe. However, gout can also manifest in the ankle, knee, or other joints. To understand gout, we will explore its underlying causes and mechanisms.

Gout is closely linked to elevated uric acid levels in the blood, a condition known as hyperuricemia.1 Uric acid is a natural waste product created when the body breaks down purines and substances in certain foods and body tissues. Usually, the kidneys efficiently filter and remove excess uric acid from the body. However, this process is disrupted in individuals with gout, accumulating uric acid crystals in the joints.

Gout typically affects one joint at a time, often starting in the big toe.

How Gout is Distinguished from Other Types of Arthritis

Distinguishing gout from other types of arthritis is essential for accurate diagnosis and treatment. While gout shares some symptoms with other forms of arthritis, such as rheumatoid arthritis and osteoarthritis, it possesses distinctive characteristics that set it apart:

  • Sudden Onset: Gout attacks often come on suddenly and intensely, making them stand out from the gradual progression of other arthritic conditions.
  • Monoarthritis: Gout typically affects one joint at a time, whereas other forms of arthritis can involve multiple joints simultaneously.
  • Location: The hallmark of gout is its predilection for the big toe, although it can affect other joints. In contrast, rheumatoid arthritis tends to affect smaller joints symmetrical, while osteoarthritis primarily impacts weight-bearing joints.
  • Uric Acid Crystals: The presence of uric acid crystals in joint fluid, identified through joint aspiration, is a definitive diagnostic marker for gout.

What are the common Symptoms of Gout?

Recognizing the symptoms of gout is crucial for prompt diagnosis and effective management. The most common symptoms of gout include:

  • Gout Pain: Gout attacks are notorious for their severe pain in the affected joint, such as the gout in the foot or big toe. This intense pain can make even the lightest touch unbearable.2
  • Swelling and Redness: During a gout flare-up, the affected joint becomes visibly swollen, red, and tender to the touch. This inflammation results from the body's immune response to uric acid crystals.
  • Limited Range of Motion: Gout can temporarily limit the joint's range of motion due to pain and swelling, making it challenging to move the joint freely.
  • Warmth: The affected joint may feel warm to the touch due to the inflammation caused by uric acid crystals.
  • Unwellness: Alongside the physical symptoms, gout attacks can be associated with fatigue, a general feeling of unwellness, and fever.
The frequency of gout flares varies among individuals.

 

How Frequent Does a Gout Flare Occur?

The frequency of gout flares varies among individuals—some experience infrequent episodes, while others have recurring attacks. Several factors influence the frequency of gout flare-ups, including genetics, lifestyle, and underlying health conditions.2

Gout flares tend to be more common in the initial stages of the disease but can become less frequent with appropriate management. Understanding what triggers gout attacks can aid in reducing their recurrence.

How Long Does a Gout Flare Last?

A gout flare can range from a few days to several weeks, with the average episode lasting about three to ten days. It is essential to note that without treatment, gout attacks can last longer and become more frequent.

Various factors, including the promptness of treatment and the effectiveness of medications, can influence the duration of a gout flare. Those who seek medical attention promptly and adhere to their treatment plan are more likely to experience shorter and less severe gout attacks.

The Science Behind Gout

Gout, often called the "disease of kings," has intrigued medical experts for centuries due to its unique pathophysiology. To gain a more profound insight into gout, we should learn how uric acid influences gout flares and the intricate crystallization process within affected joints.

How Does Uric Acid Affect Gout Flares?

Uric acid is a natural byproduct of the body's metabolic processes, and its levels are regulated by the kidneys, which excrete excess uric acid through urine.

Excess uric acid can crystallize within the joints, setting the stage for gout flares. These microscopic urate crystals can trigger an inflammatory response by the body's immune system. This inflammatory response leads to the classic symptoms of gout, including intense pain, swelling, redness, and warmth in the affected joint.

The exact mechanisms through which urate crystals incite inflammation are still the subject of ongoing research, but they are believed to activate specific immune cells and release inflammatory mediators. This process ultimately results in the characteristic gout symptoms.

Medications that lower uric acid levels, such as allopurinol and febuxostat, are commonly prescribed to prevent gout flares and reduce the risk of complications.

The crystallization of uric acid within the joints is a central feature of gout pathophysiology

Crystallization Process in Joints

The crystallization of uric acid within the joints is a central feature of gout pathophysiology. This process, known as urate crystal deposition, occurs when urate crystals accumulate and form needle-like structures in the joint space.

Urate crystals can form due to several factors, including:

  • Hyperuricemia: Elevated levels of uric acid in the bloodstream increase the likelihood of crystal formation.
  • Joint Microenvironment: Changes in the joint microenvironment, such as variations in temperature and pH, can influence crystal formation.
  • Injury or Trauma: Physical stress or injury to a joint can provide an ideal environment for urate crystal deposition.

Once urate crystals form, they can remain in the joint indefinitely, causing persistent inflammation and damage if left untreated. Over time, these crystals can lead to the development of tophi, lumps of urate crystals that can protrude through the skin. Tophi are typically found in areas with cooler temperatures, such as the earlobes and fingers.

The presence of urate crystals in joint fluid can be confirmed through joint aspiration or arthrocentesis. This diagnostic test involves withdrawing fluid from the affected joint and examining it under a microscope to identify the characteristic needle-shaped urate crystals.

What Triggers Gout?

Understanding the triggers of gout attacks is essential for managing the condition effectively. Gout is often described as an episodic disease, with periods of relative remission interspersed with acute flare-ups. Several factors can contribute to the onset of gout attacks, and these triggers can vary from person to person.

Dietary Factors

Diet plays a significant role in the development and management of gout.3 Certain dietary choices can contribute to elevated uric acid levels, increasing the risk of gout flares. Key dietary factors to consider include:

  • Purine-Rich Foods: Purines are naturally occurring compounds found in some foods. When the body metabolizes purines, uric acid is produced. Foods high in purines, such as red meat, organ meats, seafood (especially shellfish), and some types of beans, can raise uric acid levels. Limiting the consumption of these foods can be beneficial for individuals with gout.
  • Fructose: High fructose intake, often found in sugary beverages and foods, has been linked to an increased risk of gout.
  • Alcohol: Alcohol, particularly beer and spirits, can hinder the body's ability to excrete uric acid, leading to higher uric acid levels.
  • Dehydration: Inadequate hydration can contribute to uric acid buildup. Staying well-hydrated by drinking plenty of water is essential for managing gout.
Certain medications and medical conditions can either trigger gout attacks or exacerbate the condition.

Medications and Medical Conditions

Certain medications and medical conditions can either trigger gout attacks or exacerbate the condition:

  • Diuretics: Some diuretics, often prescribed for high blood pressure and heart conditions, can increase uric acid levels.
  • Aspirin: High doses of aspirin can interfere with uric acid excretion and potentially worsen gout symptoms.
  • Medical Conditions: Conditions such as hypertension, diabetes, and metabolic syndrome can be associated with elevated uric acid levels and an increased risk of gout.

Genetic Predisposition

Genetics can play a role in gout susceptibility. Some individuals have a genetic predisposition to hyperuricemia and gout. If you have a family history of gout, you may be at a higher risk of developing the condition. Understanding your genetic risk factors can help you and your healthcare provider tailor your gout management plan accordingly.

By recognizing and addressing these gout triggers, individuals can take proactive steps to reduce the frequency and severity of gout attacks. However, gout management extends beyond trigger avoidance.

Can Gout Be Cured?

Gout is considered a chronic condition, and while it can be effectively managed, it is typically not considered curable in the traditional sense. However, this does not mean that individuals with gout cannot lead a normal, pain-free life. Understanding the nature of gout and its management options is essential to control the disease and prevent future gout attacks effectively.4

The primary goal of gout treatment is to:

  1. Relieve Symptoms: Acute gout flares can be excruciatingly painful. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids are commonly used to alleviate pain, reduce inflammation, and shorten the duration of flare-ups.
  2. Lower Uric Acid Levels: Long-term management involves addressing the underlying cause of gout: elevated uric acid levels. Medications like allopurinol, febuxostat, and probenecid are prescribed to lower uric acid levels and prevent future gout attacks.
  3. Prevent Complications: If left untreated, gout can lead to complications such as joint damage and the formation of tophi (deposits of urate crystals). Proper management can help prevent these complications.

Who Are Mostly at Risk of Gout?

Gout can affect people of various backgrounds, but certain factors increase the risk of developing this painful condition.2 Understanding these risk factors can help individuals take proactive steps to prevent gout or manage it effectively if it occurs.

Age and Gender

  • Men: Gout is more common in middle-aged and older men. This gender disparity is largely attributed to hormonal differences, with estrogen having a protective effect against hyperuricemia.
  • Postmenopausal Women: While gout is less common in women of reproductive age, the risk increases after menopause due to hormonal changes.

Family History

A family history of gout can significantly elevate an individual's risk. Genetic factors can influence the body's handling of uric acid and predispose individuals to hyperuricemia and gout.

Diet and Lifestyle

  • Dietary Choices: Diets high in purine-rich foods, excessive alcohol consumption, and sugary beverages can increase uric acid levels. These dietary habits increase the risk of gout.
  • Obesity: Excess body weight is associated with an increased risk of gout. Obesity can lead to both insulin resistance and increased uric acid production, making weight management an important aspect of gout prevention.5

Medical Conditions

Certain medical conditions5 are linked to an increased risk of gout:

  • Hypertension: High blood pressure is often seen in individuals with gout.
  • Diabetes: Type 2 diabetes and gout share common risk factors, such as obesity and metabolic syndrome.
  • Kidney Disease: Impaired kidney function can hinder the excretion of uric acid, leading to elevated levels.

Medications

As mentioned, some medications, including diuretics and high-dose aspirin, can contribute to hyperuricemia and gout.

Lifestyle Factors

Sedentary lifestyles and lack of physical activity can increase the risk of gout. Regular exercise and maintaining a healthy weight can help mitigate this risk.

Understanding these risk factors can empower individuals to make informed diet, lifestyle, and healthcare choices. While some risk factors, such as genetics and age, cannot be modified, addressing modifiable risk factors through lifestyle changes and medical management can significantly reduce the likelihood of developing gout or experiencing frequent gout attacks.

Regular exercise and maintaining a healthy weight can help mitigate this risk.

Can You Reduce The Risk of Developing Gout?

Yes, it is possible to reduce the risk of developing gout through lifestyle modifications and, in some cases, medications. Taking proactive steps to prevent gout is especially important for individuals with risk factors such as a family history of the condition or underlying medical conditions.4

Here are strategies to reduce the risk of developing gout:

Maintain a Healthy Diet

  • Limit Purine-Rich Foods: Reduce consumption of foods high in purines, such as red meat, organ meats, seafood, and certain beans.
  • Moderate Alcohol: If you consume alcohol, do so in moderation, and consider choosing beverages with lower purine content, like wine.
  • Stay Hydrated: Drink plenty of water to help flush excess uric acid from the body.

Manage Weight

  • Achieve and Maintain a Healthy Weight: If you are overweight or obese, losing weight can lower your risk of gout. However, avoid crash diets, as rapid weight loss can temporarily increase uric acid levels.

Stay Active

  • Engage in Regular Physical Activity: Exercise helps control weight and improve insulin sensitivity, reducing the risk of gout.

Medications

  • Consult Your Healthcare Provider: If you have risk factors for gout, such as a family history or medical conditions, discuss preventive medications with your healthcare provider. These may include medications that lower uric acid levels.

Monitor Uric Acid Levels

  • Regular Testing: If you are at high risk of gout, your healthcare provider may recommend periodic uric acid level monitoring. This can help detect elevated levels early and guide preventive measures.

Avoid Dehydration

  • Stay Hydrated: Dehydration can contribute to uric acid buildup. Ensure you drink enough fluids, especially in hot weather or during illness.

By implementing these preventive measures, individuals can significantly reduce their risk of developing gout and enjoy a healthier, more active life.

If you have concerns about gout or its risk factors, consult a healthcare professional for personalized guidance and recommendations tailored to your unique circumstances.

Risk Factors and Comorbidities

Gout is a complex condition influenced by various risk factors and comorbidities. Understanding how certain factors contribute to gout can help individuals and healthcare providers develop effective strategies for management and prevention.

Obesity and Gout

Obesity is a well-established risk factor for gout. Excess body weight, especially when it accumulates around the abdomen, can lead to multiple metabolic abnormalities that contribute to the development of gout.5 Here's how obesity and gout are interconnected:

  • Insulin Resistance: Obesity often leads to insulin resistance, a condition in which the body's cells don't respond effectively to insulin. Insulin resistance can increase uric acid levels by reducing the excretion of uric acid through the kidneys.
  • Increased Uric Acid Production: Obesity is associated with higher levels of uric acid production in the body, further elevating uric acid concentrations in the blood.
  • Chronic Low-Grade Inflammation: Adipose tissue (fat) produces pro-inflammatory substances. Chronic inflammation can contribute to gout flares.
  • Joint Stress: Excess body weight places added stress on weight-bearing joints, such as the knees and feet. This mechanical stress can increase the risk of gout flares in these joints.

Managing and preventing gout in individuals with obesity often involves a combination of lifestyle modifications and medications. Weight loss through a balanced diet and regular exercise can be particularly effective in reducing gout risk. However, it's essential to approach weight loss gradually to avoid rapid changes in uric acid levels, which can trigger gout flares.

Managing and preventing gout in individuals with obesity often involves a combination of lifestyle modifications and medications.

Kidney Function and Gout

Kidney function plays a crucial role in the development and management of gout.6 The kidneys are responsible for filtering blood and excreting waste products, including uric acid. Impaired kidney function can lead to higher uric acid levels in the blood, increasing the risk of gout. Here's how kidney function and gout are linked:

  • Reduced Uric Acid Excretion: Kidney disease or reduced kidney function can sometimes result in decreased uric acid excretion. This can lead to uric acid buildup in the bloodstream.
  • Medication Considerations: Individuals with gout and compromised kidney function may need adjusted dosages of medications such as allopurinol to manage gout. Regular monitoring by a healthcare provider is essential to optimize treatment.
  • Fluid Balance: Kidneys are also responsible for maintaining fluid balance in the body. Dehydration can contribute to gout flares, so individuals with gout and kidney issues should prioritize staying well-hydrated.

Individuals with kidney function concerns and gout must work closely with their healthcare providers to manage both conditions effectively. Lifestyle modifications, dietary changes, and medication adjustments may be necessary to control uric acid levels and prevent gout flares.

Are There Long-Term Implications of Gout?

Gout can have long-term implications if left unmanaged and lead to several complications.1 Understanding these potential consequences highlights the importance of early diagnosis and effective management.

Joint Damage

Commonly affected joints include the big toe, ankles, knees, and fingers. To prevent joint damage, managing uric acid levels and following a treatment plan prescribed by a healthcare provider is crucial.

Tophi Formation

Tophi are lumps or nodules that develop under the skin and around joints due to the accumulation of urate crystals. Surgical procedures may be necessary to remove them in severe cases.

Reduced Joint Mobility

This limitation in joint movement can significantly impact a person's quality of life and ability to perform daily activities. Physical therapy and joint exercises may help maintain or improve joint function.

Kidney Stones

These stones can cause severe pain and may require medical intervention for removal. Managing uric acid levels can reduce the risk of kidney stone formation.

Impact on Overall Health

Gout is associated with other health conditions, such as hypertension, cardiovascular disease, and metabolic syndrome.5 Effective gout management can reduce the risk of these comorbidities and improve overall health.

Common Myths About Gout

Gout is a condition surrounded by several common myths. Dispelling these myths can help individuals better understand the condition and its management.

Myth 1: Gout Only Affects the Elderly

Fact: While gout is more common in middle-aged and older individuals, it can affect people of all ages. In some cases, even young adults and adolescents may develop gout.

Myth 2: Gout is Caused by Eating Too Much Protein

Fact: While excessive consumption of purine-rich foods can contribute to gout, it is not solely caused by protein intake. Genetics, underlying medical conditions, and lifestyle factors also play significant roles.

Myth 3: All Alcohol Triggers Gout

Fact: While alcohol can increase the risk of gout attacks, not all types of alcohol have the same effect. Beer and spirits have a more pronounced association with gout, while moderate wine consumption may have a lower risk.

Myth 4: Gout Only Affects the Big Toe

Fact: Gout can affect any joint in the body. While the big toe is a commonly affected joint, it can also involve the ankles, knees, wrists, and fingers.

Myth 5: Gout is a Sign of Excessive Rich Foods Consumption

Fact: Gout is not solely a result of overindulgence in rich foods. Genetic factors, obesity, and underlying health conditions also contribute to its development.

Myth 6: Gout Will Go Away on Its Own

Fact: Gout is a chronic condition that requires ongoing management. Gout flares can be excruciatingly painful and may not resolve without appropriate treatment.

How is Gout Diagnosed?

Diagnosing gout involves a combination of clinical evaluationmedical history, and laboratory tests.7 Accurate diagnosis is crucial to initiate appropriate treatment and prevent long-term complications.

  1. Review of Medical History: The provider will ask about symptoms, previous gout attacks, family history, and any underlying health conditions.
  2. Physical Examination: The affected joint(s) will be examined for signs of inflammation, pain, and tophi (if present).
  3. Laboratory Tests: Several laboratory tests are used to confirm a gout diagnosis:
  4. Serum Uric Acid Test: This blood test measures uric acid levels. However, normal uric acid levels do not rule out gout, as gout attacks can occur even when levels are within the normal range.
  5. Synovial Fluid Analysis: If available, synovial fluid from the affected joint may be aspirated and examined for the presence of urate crystals. This is the most definitive diagnostic test for gout.
  6. Imaging: In some cases, imaging tests such as X-raysultrasound, or dual-energy CT scans may be performed to assess joint damage and the presence of tophi.
  7. Differential Diagnosis: Gout can mimic other conditions, such as rheumatoid arthritis and septic arthritis. Differential diagnosis is essential to distinguish gout from other joint disorders.
Seek medical advice when needed.

In complex or challenging cases, a referral to a rheumatologist (a specialist in arthritis and related conditions) may be necessary to further evaluate and confirm the diagnosis.

Once diagnosed, individuals can work with their healthcare providers to develop a tailored treatment plan to relieve symptoms, reduce uric acid levels, and prevent future gout attacks.

Gout Treatment Options

Treatment for gout focuses on managing symptomslowering uric acid levels, and preventing future gout flares1 Treatment choice depends on the individual's gout severity, frequency of flares, and other health considerations. It's important to note that healthcare providers should guide and prescribe treatment.

Acute Gout Flare Treatment

Medications

  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs like ibuprofen and indomethacin can help relieve pain and reduce inflammation during a gout flare.
  • Colchicine: This medication can alleviate gout pain and inflammation, especially in cases where NSAIDs are not recommended.
  • Corticosteroids: Injections of corticosteroids into the affected joint or oral corticosteroids can provide rapid relief from gout symptoms.

Long-Term Gout Management

Medications

Xanthine Oxidase Inhibitors (Allopurinol, Febuxostat): These medications lower uric acid production and are often used for long-term gout management.

Uricosuric Agents (Probenecid): Uricosuric agents increase the excretion of uric acid by the kidneys.

Pegloticase: This medication is reserved for severe cases when other treatments are ineffective. It converts uric acid into a substance that the body can excrete.

Lifestyle Modifications

Dietary Changes: Limiting purine-rich foods and moderating alcohol consumption can help manage uric acid levels.

Weight Management: Achieving and maintaining a healthy weight can reduce the risk of gout flares.

Hydration: Staying well-hydrated can prevent uric acid buildup.

Monitoring

Regular check-ups with healthcare providers are essential to monitor uric acid levels, assess joint health, and adjust treatment plans as needed.

When to Seek Medical Advice

Seeking medical advice for gout is essential, especially if you experience symptoms or associated risk factors.

It may be a gout flare if you experience sudden and severe joint pain, swelling, redness, and warmth, particularly in the big toe, ankle, or other joints. Seeking medical advice promptly can help manage the pain and initiate treatment.

Regular follow-up with a healthcare provider is crucial for individuals with gout. This allows for ongoing monitoring of uric acid levels, joint health, and the overall effectiveness of the treatment plan.

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Click here to learn how Tart Cherry may help manage your gout

What is Gout: Conclusion

Gout, characterized by intense joint pain and inflammation, is a condition primarily driven by elevated uric acid levels.

While it's not curable, effective management through lifestyle changes and medications can relieve symptoms, lower uric acid levels, and prevent complications.

Understanding gout's nature, triggers, and seeking medical guidance when necessary empowers individuals to lead pain-free lives and reduce the risk of recurrent attacks. 

Frequently Asked Questions

What are the primary symptoms of gout?

Gout symptoms include joint pain, swelling, redness, and warmth, often affecting the big toe.

Can gout be cured?

Gout is manageable, but not curable; it requires ongoing treatment and lifestyle changes.

How can I reduce the risk of developing gout?

Reducing gout risk involves maintaining a healthy weight, moderating alcohol, and avoiding purine-rich foods.

What are tophi in gout?

Tophi are lumps or nodules that form due to urate crystal accumulation and can develop around joints in advanced gout.

Are supplements effective for gout management?

Supplements can complement gout treatment, but their use should be discussed with a healthcare provider.

Medical Disclaimer:

The information provided in this article is for educational and informational purposes only and should not be considered a substitute for professional medical advice, diagnosis, or treatment. Please consult with your healthcare provider before starting any new dietary supplement, especially if you are pregnant, nursing, have a medical condition, or are taking other medications. Never disregard professional medical advice or delay in seeking it because of something you have read in this article.

References:

  1. George C, Minter DA. Hyperuricemia. [Updated 2023 Feb 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459218/
  2. Fenando A, Rednam M, Gujarathi R, et al. Gout. [Updated 2022 Dec 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546606/
  3. Yokose C, McCormick N, Choi HK. The role of diet in hyperuricemia and gout. Curr Opin Rheumatol. 2021 Mar 1;33(2):135-144. doi: 10.1097/BOR.0000000000000779. PMID: 33399399; PMCID: PMC7886025.
  4. Shekelle PG, FitzGerald J, Newberry SJ, et al. Management of Gout [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Mar. (Comparative Effectiveness Reviews, No. 176.) Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK356136/
  5. Evans PL, Prior JA, Belcher J, Mallen CD, Hay CA, Roddy E. Obesity, hypertension and diuretic use as risk factors for incident gout: a systematic review and meta-analysis of cohort studies. Arthritis Res Ther. 2018 Jul 5;20(1):136. doi: 10.1186/s13075-018-1612-1. PMID: 29976236; PMCID: PMC6034249.
  6. Srivastava A, Kaze AD, McMullan CJ, Isakova T, Waikar SS. Uric Acid and the Risks of Kidney Failure and Death in Individuals With CKD. Am J Kidney Dis. 2018 Mar;71(3):362-370. doi: 10.1053/j.ajkd.2017.08.017. Epub 2017 Nov 11. PMID: 29132945; PMCID: PMC5828916.
  7. Branch, N. S. C. A. O. (2023, July 27). Gout. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/health-topics/gout/diagnosis-treatment-and-steps-to-take
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