What is the treatment for a patient with a blood blister, considering potential underlying bleeding disorders or anticoagulant therapy (anticoagulant therapy)?

Blood Blister Treatment

For a blood blister in a patient on anticoagulation, continue the anticoagulant and apply local therapy with manual compression, as this represents a non-major bleed that does not require reversal or interruption of anticoagulation. 1

Initial Assessment

Determine if this is a major bleed by checking for any of the following criteria 1:

• Bleeding at a critical site (intracranial, intraocular, spinal, pericardial, intra-articular, intramuscular with compartment syndrome, or retroperitoneal)
• Hemodynamic instability
• Hemoglobin decrease ≥2 g/dL or need for ≥2 units RBC transfusion

A blood blister does not meet any of these criteria and is classified as a non-major bleed. 1

Management for Non-Major Bleeding

Continue Anticoagulation

Continue oral anticoagulation therapy without interruption, as the thrombotic risk of stopping anticoagulation outweighs the bleeding risk from a blood blister. 1, 2

Local Therapy

Apply the following measures 1:

• Manual compression for 3-5 minutes directly to the blister site
• Avoid rupturing the blister initially, as the intact roof provides a sterile barrier
• If the blister is large and tense, consider aseptic drainage while preserving the blister roof 3
• Apply a non-adherent dressing after achieving hemostasis

Specific Considerations for Anticoagulated Patients

If the patient is on concomitant antiplatelet therapy, assess the risks and benefits of continuing both agents, but do not routinely stop either medication for a blood blister. 1

Assess for and manage comorbidities that could contribute to bleeding 1:

• Thrombocytopenia (check platelet count)
• Uremia (check renal function)
• Liver disease (check hepatic function)
• Supratherapeutic anticoagulation levels

Determine if the dosing of the oral anticoagulant is appropriate by checking drug levels if applicable (INR for warfarin, anti-Xa levels for DOACs if available). 1

When to Consider Stopping Anticoagulation

Only temporarily hold anticoagulation if 1:

• The blister becomes infected and requires surgical intervention
• Multiple blood blisters develop suggesting a more systemic bleeding problem
• The patient develops signs of major bleeding from another source

Special Populations

Patients with Bleeding Disorders

For patients with hemophilia or other bleeding disorders, intramuscular injections and trauma should be avoided, but a blood blister can be managed with local compression using a fine needle (<23 gauge) if drainage is needed, followed by firm pressure for >2 minutes. 1

Patients on Warfarin vs. DOACs

The management approach is identical regardless of anticoagulant type for non-major bleeding like blood blisters—continue the medication and apply local therapy. 1

Common Pitfalls

Do not routinely administer vitamin K, prothrombin complex concentrates, or DOAC reversal agents for a blood blister, as these are reserved for major bleeding only. 1

Do not routinely transfuse platelets in patients on antiplatelet therapy with a blood blister, as this has not been shown to improve outcomes and may cause harm. 1

Avoid using adhesive dressings that could cause tension blisters or skin tears in anticoagulated patients with fragile skin. 4