What is the best treatment for a patient with painful, potentially infected foot blisters and significant ambulatory pain?

Management of Painful Foot Blisters in a Non-Diabetic Patient

The most appropriate treatment for this patient with painful, potentially infected foot blisters is proper wound cleansing, debridement of any necrotic tissue, appropriate dressing, off-loading of pressure, and pain management with acetaminophen rather than ibuprofen. 1

Assessment of the Wound

Classification of Infection Status

First, determine if the blisters are infected by checking for:

• Signs of inflammation (redness, warmth, swelling, tenderness)
• Purulent secretions
• Secondary signs (non-purulent secretions, friable granulation tissue, undermining of wound edges)

Based on the patient's presentation, there are signs of inflammation (pain) but no clear evidence of systemic infection (no fever). This suggests a mild infection or pre-ulcerative condition.

Treatment Plan

1. Wound Cleansing

• Clean the wounds with normal saline or tap water
• Avoid continued use of hydrogen peroxide as it can be toxic to healthy tissue and delay wound healing 2
• Discontinue Neosporin use as topical antibiotics are generally not recommended for routine wound care unless clearly infected 1

2. Debridement

• Gently remove any necrotic tissue or excessive callus
• Drain any remaining intact blisters if necessary 1
• This should be done carefully to avoid further tissue damage

3. Wound Dressing

Select appropriate dressing based on wound characteristics:

• For moist blisters: Alginates or foams to absorb exudate 1
• For dry wounds: Hydrogels to maintain moisture 1
• Apply non-adherent dressing to prevent further damage when changing dressings

4. Off-loading

• This is critical for healing and pain management
• Continue non-weight bearing as much as possible
• When ambulation is necessary, use crutches or a wheelchair
• When shoes must be worn, ensure they are properly fitted with ample room (1-2 cm longer than foot and width equal to widest part of foot) 1

5. Pain Management

• Use acetaminophen for pain control 3
• Avoid ibuprofen due to:
  1. Patient's habitual avoidance related to daughter's Crohn's disease
  2. Potential side effects including gastrointestinal bleeding 4

6. Antibiotic Therapy

• If clear signs of infection develop (increasing redness, warmth, swelling, purulence):
  • Consider oral antibiotics targeting gram-positive cocci, particularly staphylococci 1
  • Cephalexin would be appropriate for mild infections without risk factors for resistant organisms 5
  • Duration of 1-2 weeks is typically adequate for mild infections 1

Follow-up and Monitoring

• Reassess in 2-3 days to evaluate healing progress and infection status
• Watch for warning signs requiring immediate attention:
  • Increasing pain, redness, or swelling
  • Purulent drainage
  • Systemic symptoms (fever, chills)
  • Failure to improve within 48-72 hours

Important Considerations and Pitfalls

1. Avoid common mistakes:

   • Using antiseptics like hydrogen peroxide routinely (can damage healthy tissue)
   • Neglecting off-loading (critical for healing)
   • Prescribing antibiotics for uninfected wounds (increases resistance risk)

2. Special attention for this patient:

   • The significant pain with ambulation indicates need for strict off-loading
   • The punctured blister has higher infection risk and requires closer monitoring
   • The extensive involvement of both feet requires careful attention to mobility assistance

By following this approach, the patient should experience pain relief and proper healing of the blisters without complications.