What is the recommended management for blisters?

Recommended Blister Management

The recommended approach for blister management is to leave small to medium blisters intact, while large or painful blisters should be drained by piercing with a sterile needle while preserving the blister roof as a biological dressing. 1

Assessment and Decision Algorithm

1. Blister Evaluation:
   • Small to medium, non-painful blisters → Leave intact
   • Large or painful blisters → Drain while preserving roof
   • Pressure-painful blisters (especially on palms/soles) → Puncture and preserve roof
   • Ruptured blisters without infection → Leave remnants of blister roof
   • Ruptured blisters with signs of infection → Remove remnants of blister roof
   • Burns (grade 2a or higher) → Remove blister roof 1, 2

Drainage Technique for Large Blisters

1. Preparation:

   • Clean the blister with antiseptic solution
   • Consider providing analgesia before the procedure if patient reports pain 3

2. Drainage Procedure:

   • Pierce blister at the base with a sterile needle (bevel facing up)
   • Select a drainage site where fluid will drain by gravity to prevent refilling
   • Gently apply pressure with sterile gauze to facilitate drainage
   • Do not remove the blister roof as it serves as a biological dressing 3, 1

3. Post-Drainage Care:

   • Cleanse again with antimicrobial solution after drainage
   • Apply a non-adherent dressing if necessary 3
   • For large blisters, multiple drainage holes may be required 3

Wound Care and Infection Prevention

1. Dressing Application:

   • Apply a non-adherent dressing over the blister or drained blister
   • Options include plain petrolatum ointment with bandage over open areas
   • For painful areas, use low-adhesion dressings such as Mepitel or Atrauman 3

2. Infection Prevention:

   • Monitor for signs of infection
   • For extensive areas of erosion, antiseptic baths or soaks (e.g., potassium permanganate) may help dry lesions and prevent infection
   • Consider antiseptic-containing bath oils for widespread areas 3, 1
   • Daily washing with antibacterial products can decrease colonization 3

3. Pain Management:

   • Provide appropriate analgesia for both background pain and procedural pain
   • Consider cold compresses intermittently for the first 24-48 hours to reduce swelling 1

Special Considerations

1. Friction Blisters:

   • Evidence suggests draining intact blisters while maintaining the roof results in less discomfort and may reduce infection risk 4
   • Hydrocolloid dressings can provide pain relief for deroofed blisters 4

2. Burn Blisters:

   • For superficial burns, puncture in a sterile way and keep overlying skin as biological cover 5
   • For deeper burns (grade 2a or higher), consider removal of the blister roof 1, 2

3. Monitoring:

   • Document the number and location of blisters to track healing progress
   • Watch for signs of infection requiring systemic antibiotics 3

Important Cautions

• Avoid forcefully rupturing blisters
• Never apply ice directly to blisters
• Avoid alcohol-containing products on damaged skin
• Avoid home remedies that may introduce infection or delay healing 1
• Triple antibiotic ointment (neomycin, polymyxin B, bacitracin) has been shown to promote faster healing and eliminate bacterial contamination in blister wounds 6

The British Association of Dermatologists guidelines emphasize that blisters should generally be left intact when possible, as this helps prevent secondary bacterial infection. This approach minimizes complications while promoting optimal healing and reducing discomfort.