Management of Large Heel Blood Blister in an Elderly Patient
For a large, non-painful blood blister (hematoma) on the plantar heel in an elderly patient not on anticoagulants, pierce the blister with a sterile needle at its lowest point to drain the fluid while leaving the blister roof intact, then apply appropriate low-adhesion dressing. 1
Immediate Blister Management
Pierce the intact blister to prevent enlargement under pressure. The British Association of Dermatologists explicitly recommends that when blisters are particularly large or located on sites like the sole of the foot where they interfere with function, they should be pierced with a sterile needle to release fluid while preserving the blister roof 1. This approach is critical because:
- Large blisters on weight-bearing surfaces will continue to enlarge under pressure if left intact 1
- The blister roof provides natural protection against secondary bacterial infection when kept in place 1
- Lance at the lowest point to facilitate gravity-assisted drainage 1
Wound Protection and Dressing
After draining the blister:
- Apply a low-adhesion dressing such as Mepilex or Atraumatec held in place with soft elasticated viscose to protect the area 1
- Avoid adhesive dressings that could cause friction and create new blisters 1
- Consider antiseptic measures if there are concerns about infection, such as antiseptic-containing preparations, though this is typically reserved for extensive erosions 1
Assessment for Underlying Causes
Evaluate the patient for:
- Pre-ulcerative lesions or excess callus that may have contributed to the hematoma formation, as these are strong predictors of future complications in elderly patients 1
- Footwear assessment to identify sources of friction or pressure that caused the blister 1
- Biomechanical factors including gait abnormalities or pressure distribution issues that increase plantar stress 1
Prevention of Recurrence
- Provide immediate footwear education to prevent repeat injury, focusing on proper shoe fit and cushioning materials 1
- Consider pressure-relieving insoles or cushioning for the heel area once the blister heals 1
- Monitor for signs of infection, particularly given elderly patients' increased vulnerability 1
Important Caveats
Do not routinely use vasopressors or aggressive interventions unless there is evidence of systemic compromise, which would be unusual for an isolated heel hematoma 1. The non-painful nature suggests this is a simple traumatic blood blister rather than a manifestation of systemic disease.
Avoid leaving large blisters intact on the plantar surface despite general recommendations to preserve blisters elsewhere on the body—the weight-bearing nature of the heel makes drainage essential 1.