What are the treatments for burns with blisters?

Treatment of Burns with Blisters

Leave burn blisters intact and cover them loosely with a sterile dressing—this approach improves healing and reduces pain. 1

Immediate Cooling (If Presenting Acutely)

• Cool the burn with cold tap water (15° to 25°C) as soon as possible and continue for at least 5-20 minutes until pain is relieved 1, 2
• This reduces pain, edema, depth of injury, speeds healing, and may reduce the need for surgical excision and grafting 1
• Do not apply ice directly—it can cause tissue ischemia and further damage 1, 2
• Avoid prolonged cooling of large burns (>20% TBSA in adults, >10% in children) as this risks hypothermia 1, 2

Blister Management: The Critical Decision

The evidence strongly supports leaving blisters intact rather than unroofing them. 1, 2

Conservative Approach (Preferred)

• Leave the detached epidermis in place to act as a biological dressing 1, 2
• If blisters are tense and causing significant discomfort, decompress by piercing and aspirating the fluid while preserving the blister roof 1, 3
• Never completely unroof or remove the overlying skin—this increases infection risk and worsens outcomes 3, 4

The rationale is straightforward: the blister roof provides natural biological protection that improves healing and reduces pain. 1 While blister fluid contains pro-inflammatory mediators, the protective benefit of the intact epidermis outweighs theoretical concerns about inflammatory content. 5

Wound Cleansing

• Gently irrigate wounds with warmed sterile water, saline, or dilute chlorhexidine (1:5000) 1, 2
• Thorough irrigation removes foreign matter and debris 1, 2
• Perform wound care in a clean environment with adequate pain control 2, 4

Dressing Application

Primary Layer

• Apply a greasy emollient such as 50% white soft paraffin with 50% liquid paraffin over the entire burn surface, including intact blisters 1, 2, 3
• Alternatively, use petrolatum-based antibiotic ointment, medical-grade honey, or aloe vera 2
• These moist dressings significantly reduce complications including hypertrophic scarring compared to dry dressings 2

Secondary Layer

• Cover with non-adherent dressings such as Mepitel™ or Telfa™ directly over the emollient 1, 2, 3
• Apply a secondary foam or burn dressing (such as Exu-Dry™) to collect exudate 1

Antimicrobial Management: A Nuanced Approach

Apply topical antimicrobial agents ONLY to sloughy or obviously infected areas—not routinely to all burn wounds. 1, 3

• Silver sulfadiazine should be applied to a thickness of approximately 1/16 inch once to twice daily if used, but avoid prolonged use on superficial burns as it may delay healing 2, 6
• Systemic antibiotic prophylaxis should not be administered routinely 2
• Reserve topical antibiotics for infected wounds only to prevent antimicrobial resistance 2, 4

This represents a shift from older practices that routinely applied silver sulfadiazine to all burns. Current evidence shows that uninfected wounds heal better without routine antimicrobials. 2

Pain Control

• Provide adequate analgesia during wound care 2, 4
• Consider over-the-counter medications (acetaminophen or NSAIDs) for mild to moderate pain 3, 4
• Short-acting opioids and ketamine are effective for severe burn-induced pain 2
• Non-pharmacological measures like cooling and appropriate dressings improve pain control 2, 4

When to Refer to a Burn Center

Certain burns require specialized care regardless of apparent severity:

• Burns involving face, hands, feet, or genitals 2, 3, 4
• Burns >10% TBSA in adults or >5% in children 2, 4
• All full-thickness burns 2, 4
• Signs of inhalation injury or infection 2
• Bilateral hand involvement mandates specialist evaluation even if burns appear minor 3

Critical Pitfalls to Avoid

• Never apply ice directly—causes additional tissue damage 1, 2, 3, 4
• Never completely unroof blisters—significantly increases infection risk 3, 4
• Never apply butter, oil, or home remedies—increases infection risk and delays healing 4
• Never use routine topical antibiotics on uninfected wounds—promotes antimicrobial resistance 2, 4
• Never delay specialist referral for high-risk anatomic locations (hands, face, feet, genitals) 2, 3, 4

Follow-Up Care

• Reapply dressings as needed, particularly after wound cleansing 6
• Continue treatment until satisfactory healing occurs or the burn site is ready for grafting 6
• Monitor for signs of infection: increasing pain, redness, swelling, or purulent discharge 2