What is the best approach to manage new blisters on multiple sites in a hospice patient?

Management of New Blisters in Hospice Patients

In a hospice patient with new blisters on multiple sites, prioritize comfort-focused wound care by gently cleansing with antimicrobial solution, leaving blister roofs intact as biological dressings, applying bland emollient, and using antimicrobials only if infection causes distressing symptoms—not for life prolongation. 1, 2

Initial Assessment Priorities

The first step is determining whether these blisters are causing symptom burden that impacts comfort, rather than pursuing aggressive diagnostic workup. 3

Key clinical features to evaluate:

• Symptom burden: Assess pain, pruritus, and functional impairment from the blisters 4
• Signs of infection: Look for surrounding erythema, purulent drainage, fever, or increased pain suggesting secondary bacterial infection 1, 5
• Distribution pattern: Multiple sites suggest either autoimmune bullous disease (like bullous pemphigoid common in elderly), drug reaction, or widespread infection 4

Comfort-Focused Wound Care Approach

For intact blisters:

• Leave blisters intact whenever possible, as the blister roof serves as a natural biological dressing and reduces infection risk 4, 1
• If blisters are large, tense, or causing significant discomfort, pierce with sterile needle at the base to drain fluid while preserving the roof 4, 6
• Apply gentle pressure with sterile gauze to express fluid 6

For ruptured blisters:

• Leave remnants of blister roof in place unless clinical signs of infection are present 1, 7
• If infected (purulent, malodorous, or causing systemic symptoms), remove necrotic roof remnants 1

Universal wound care measures:

• Gently cleanse with warmed sterile water, saline, or dilute chlorhexidine (1:5000) 4, 1
• Apply bland emollient such as 50% white soft paraffin with 50% liquid paraffin over all affected areas 4, 1, 6
• Cover with non-adherent dressing like Mepitel™ or Telfa™ if needed for protection or exudate management 4, 1

Infection Management in the Hospice Context

Critical principle: Antimicrobials in hospice should be used for symptom control, not life prolongation. 2, 8

When to consider antimicrobials:

• Only if infection is causing distressing symptoms (pain, malodor, excessive drainage) that impact quality of life 2, 8
• Symptom control rates are approximately 40% for skin/subcutaneous infections in hospice patients 5
• Urinary tract infections respond better to antimicrobials (higher symptom control) than respiratory or skin infections in this population 2

If antimicrobials are warranted for symptom control:

• Obtain wound culture if feasible to guide therapy (E. coli is most common pathogen in hospice patients) 5
• Use narrow-spectrum oral agents: first-generation cephalosporin, semi-synthetic penicillin, or clindamycin for skin infections 1, 8
• Choose shortest duration appropriate—typically 5-7 days 8
• Be aware that antimicrobials cause nausea, diarrhea, and rash in 10-20% of patients, adding to symptom burden 8

Important caveat: Antimicrobial use does not affect survival in hospice patients, so the decision should rest solely on symptom management goals. 5, 2

Topical Antimicrobial Considerations

• Apply topical antimicrobials (silver-containing products) only to sloughy or clinically infected areas, not prophylactically 4, 6
• Short-term use is appropriate when signs of local infection are present 6
• Take bacterial cultures from three lesional areas on alternate days if extensive erosions develop 4

When Autoimmune Disease is Suspected

If the clinical picture suggests bullous pemphigoid (elderly patient, urticarial plaques preceding blisters, pruritus):

For localized disease (few blisters, limited body sites):

• Apply clobetasol propionate 0.05% cream 10-20 g daily to lesional skin only 4, 1
• This provides symptom control without systemic side effects 4

For extensive disease (>10 new blisters daily or large body surface area):

• Consider whether aggressive treatment aligns with hospice goals of care 4, 3
• If pursuing treatment for comfort, topical clobetasol 30-40 g daily over entire body is preferred over systemic steroids due to lower mortality risk 4
• Systemic steroids (prednisone 0.5 mg/kg) have higher mortality in elderly patients and may not be appropriate in hospice 4

Practical Daily Management

• Document number and location of new blisters daily to track progression 1, 6
• Change dressings using aseptic technique 4, 6
• Monitor for psychological distress, which is significantly associated with infections in hospice patients 5
• Reassess within 24-48 hours to ensure comfort measures are adequate 1

Common Pitfalls to Avoid

• Avoid aggressive diagnostic workup (skin biopsies, extensive serologies) unless results will change comfort-focused management 3
• Do not routinely remove blister roofs—this increases infection risk and pain 4, 1, 7
• Do not use antimicrobials prophylactically or for asymptomatic colonization 4, 2
• Avoid high-dose systemic steroids in elderly hospice patients due to increased mortality risk 4
• Do not pursue treatment that conflicts with comfort goals—safety measures focused on reducing morbidity/mortality may be inappropriate when goals focus on comfort 3