Do you deroof (de-roof) blisters in burn patients?

Management of Burn Blisters

Burn blisters should not be deroofed but instead should be decompressed by piercing, leaving the blister roof intact to act as a biological dressing. 1, 2

Recommended Blister Management Protocol

1. Initial Assessment:

   • Evaluate burn severity and extent (TBSA)
   • Identify if the burn involves face, hands, feet, genitalia (requires specialist referral)
   • Assess for signs of infection

2. Blister Management Technique:

   • Gently cleanse the blister with antimicrobial solution, taking care not to rupture it 1
   • Pierce blister at the base with a sterile needle (bevel facing up) 1
   • Select a site where fluid will drain by gravity to discourage refilling 1
   • Apply gentle pressure with sterile gauze to facilitate drainage 1
   • Leave the blister roof intact as a biological dressing 1, 2
   • Cleanse again with antimicrobial solution after drainage 1

3. Post-Drainage Care:

   • Apply a bland emollient (e.g., 50% white soft paraffin with 50% liquid paraffin) to support barrier function 1
   • Consider applying a non-adherent dressing if necessary 1
   • For large blisters, use a larger needle and pierce more than once to ensure adequate drainage 1

Rationale for Not Deroofing

The British Association of Dermatologists explicitly recommends against deroofing blisters 1. This approach is supported by several key benefits:

1. Infection Prevention: The intact blister roof serves as a sterile biological dressing that protects the wound from contamination 2
2. Pain Reduction: Keeping the roof intact reduces pain and discomfort 3
3. Enhanced Healing: The blister fluid contains proteins and growth factors that may contribute to wound healing 4
4. Reduced Scarring: Evidence suggests better cosmetic outcomes with intact blister roofs 3

Special Considerations

• Pain Management: Offer analgesia prior to any blister procedure as many patients report pain or burning sensation during blister care 1
• Documentation: Record the number and location of new blisters on a blister chart to track disease progress 1
• Infection Monitoring: Vigilantly monitor for signs of infection, which is a significant risk and major cause of mortality 1, 5
• Larger Blisters: Some research suggests that larger blisters (greater than the patient's little fingernail) may benefit from debriding while smaller ones should be left intact 6, but the most recent and highest quality guidelines still recommend keeping all blister roofs intact 1, 2

Infection Prevention

• Daily washing with an antibacterial product to decrease colonization 1
• Change dressings using aseptic technique 1
• Consider barrier nursing for patients with extensive erosions 1
• Obtain bacterial and viral swabs from erosions showing clinical signs of infection 1
• Use systemic antibiotics only if there are clinical signs of infection 1, 5

The evidence strongly supports preserving the blister roof as a biological dressing while decompressing the fluid to relieve pressure and pain. This approach optimizes wound healing while minimizing infection risk and patient discomfort.