A 34-year-old man presented with severe pain in multiple joints. He was diagnosed with gout 4 years ago; however, he had not been administered any medication for this condition. He was obese (body mass index, 36.3 m²/kg), and laboratory tests showed increased levels of uric acid (11.4 mg/dL). Physical examination revealed severe edema and pain in the joints with tophi in the following sites: the right first metatarsophalangeal, both lateral malleoli, distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints and ears (Fig. 1). Following administration of prednisolone and colchicine, the pain improved. Despite the need for continuous treatment, he did not return to our clinic until a year later. He revisited our clinic with multiple painful and itchy yellowish papules on the anterior and posterior pretibial areas (Fig. 2A). Before visiting our clinic, he had been diagnosed with acne or folliculitis and had been prescribed a topical steroid ointment at a local clinic; however, the pain had not alleviated. We performed a dual-energy computed tomography (DECT) and skin biopsy. The DECT showed increasing signals in the left anterior and right posterior pretibial areas, suggestive of tophi (Fig. 2B). The skin-biopsy examination showed dispersed birefringence with fine needle shaped crystals and negative birefringence (Fig. 2C). Based on these findings, the patient was diagnosed with miliarial gout with classical tophi.