Bulla Evacuation Guidelines
Primary Recommendation
Pierce the bulla at its base with a sterile needle (bevel up), drain by gravity-assisted pressure, and leave the blister roof intact as a biological dressing—never deroof or aspirate with a syringe. 1
Step-by-Step Evacuation Technique
Initial Preparation
- Gently cleanse the intact bulla with an antimicrobial solution, taking care not to rupture it prematurely 1
- Offer analgesia 30-60 minutes prior to the procedure, as many patients report pain or burning sensation during blister care 1
Drainage Procedure
- Pierce the bulla at its base using a sterile needle with the bevel facing upward 1, 2
- Select the puncture site strategically where gravity will facilitate drainage and discourage refilling 1, 2
- Apply gentle pressure with sterile gauze swabs to facilitate complete drainage and absorb fluid 1, 2
- For large bullae, use a larger gauge needle and pierce multiple times to ensure adequate drainage 1
Critical "Do Not" Steps
- Never deroof (remove) the blister roof—it must remain in place to act as a natural biological dressing that protects underlying tissue 1, 2, 3
- Never aspirate with a needle and syringe, as this introduces skin flora into the space and significantly increases infection risk 4
Post-Drainage Care
- Cleanse again with antimicrobial solution after drainage is complete 1, 2
- Apply a bland emollient (50% white soft paraffin and 50% liquid paraffin) to support barrier function, reduce transcutaneous water loss, and encourage re-epithelialization 1, 2, 3
- Cover with a non-adherent dressing if needed for protection or exudate absorption 1, 2, 3
Infection Prevention and Monitoring
Daily Surveillance
- Document on a daily blister chart the number, size, and location of new or persistent bullae to track disease progression 1, 2, 3
- Monitor vigilantly for infection signs: increasing erythema, purulent drainage, warmth, tenderness, or systemic symptoms like fever 1, 3
- Infection and sepsis are significant risks and major causes of mortality in bullous diseases 1
Antimicrobial Measures
- Perform daily washing with antibacterial products to decrease colonization 1, 2
- Change dressings using aseptic technique, particularly if erosions are extensive 1, 2, 3
- Obtain bacterial and viral swabs from erosions showing clinical signs of infection before initiating antibiotics 1, 2
- Apply topical antimicrobials for short periods only when appropriate 1, 2
- Use systemic antibiotics if local or systemic signs of infection develop, guided by local antibiotic policy 1
Special Considerations
Pain Management
- Provide both acute and maintenance analgesia with ability to deliver timely additional doses during dressing changes 1
- Consider consulting a pain team for patients with extensive bullous disease 1
Pulmonary Bullae Context
The evidence provided primarily addresses dermatologic bullae (skin blisters from pemphigus, bullous diseases). For pulmonary bullae (emphysematous lung bullae), the management is entirely different:
- Pulmonary bullae require surgical evaluation if they occupy >30% of hemithorax or cause complications like infection or pneumothorax 5
- Infected pulmonary bullae may be managed with percutaneous drainage using small-caliber tubes combined with antimicrobial washing 6
- Patients with large pulmonary bullae face increased pneumothorax risk during air travel due to 30% gas volume expansion at altitude 1
Common Pitfalls to Avoid
- Deroofing the blister: This removes the natural biological barrier and increases infection risk 1, 2
- Aspiration technique: Introduces bacteria and is more uncomfortable than piercing 1, 4
- Inadequate drainage site selection: Failing to use gravity leads to refilling 1, 2
- Missing infection signs: Delayed recognition of infection increases mortality risk 1, 3
- Inadequate pain control: Leads to patient distress and poor cooperation with necessary care 1