What are the management and treatment options for a patient who develops a blood blister after administration of Xiaflex (collagenase clostridium histolyticum)?

Management of Blood Blister After Xiaflex Administration

Blood blisters following Xiaflex (collagenase clostridium histolyticum) injection should be left intact whenever possible, and if large or interfering with function, they may be pierced with a sterile needle while preserving the blister roof as a biological dressing. 1

Immediate Blister Management

Initial Assessment and Handling

• Do not rupture or deroof the blister - the intact blister roof serves as a natural biological dressing that protects against secondary bacterial infection and promotes healing 1
• Gently cleanse the blister with an antimicrobial solution, taking care not to rupture it during cleaning 1
• Document the size, location, and characteristics of the blood blister for monitoring purposes 1

When Decompression is Indicated

Large blood blisters or those interfering with hand function require drainage using the following technique 1:

• Pierce the blister at its base with a sterile needle (bevel facing up) at a site where gravity will facilitate drainage and discourage refilling 1
• Gently apply pressure with sterile gauze swabs to facilitate complete drainage and absorb fluid 1
• Leave the blister roof intact after drainage - this is critical as it acts as a protective barrier 1
• For particularly large blood blisters, use a larger gauge needle and pierce multiple times if necessary to ensure adequate drainage 1
• Gently cleanse again with antimicrobial solution after fluid has drained 1

Pain Management

• Offer analgesia prior to any blister manipulation - many patients report pain or burning sensation during blister care procedures 1
• Consider both acute procedural analgesia and background pain control as needed 1

Wound Care and Dressing Application

Topical Management

• Apply a bland emollient (such as 50% white soft paraffin and 50% liquid paraffin) to support barrier function, reduce transcutaneous water loss, and encourage re-epithelialization 1
• Consider applying a nonadherent dressing if needed for protection, particularly if the area is subject to friction or trauma 1

Infection Prevention

• Daily washing with an antibacterial product can decrease bacterial colonization 1
• Change dressings using aseptic technique to minimize infection risk 1
• Monitor closely for signs of infection (increasing erythema, warmth, purulent drainage, systemic symptoms) 1

Monitoring for Complications

Signs Requiring Intervention

Blood blisters are among the most common adverse events following Xiaflex administration, typically being mild to moderate in severity and resolving without intervention 2. However, monitor for:

• Local infection: If erosions show clinical signs of infection, obtain bacterial and viral swabs 1
• Apply topical antimicrobials for short periods only if local infection is suspected 1
• Systemic antibiotics are indicated if there are local or systemic signs of infection or extending skin infection 1

Expected Clinical Course

• Most treatment-related adverse events from Xiaflex (including blood blisters, hematoma, pain, and swelling) are mild or moderate in severity, not serious, and resolve without intervention 2
• The blood blister should gradually resorb as the underlying tissue heals 2

Critical Pitfalls to Avoid

1. Never deroof the blister - removing the blister roof increases infection risk and delays healing 1
2. Avoid aspiration - piercing is preferred over aspiration as it causes less discomfort 1
3. Do not apply adhesive dressings directly - use only low-adhesion or nonadherent dressings to prevent further trauma 1
4. Do not ignore signs of infection - infection increases scarring risk and can lead to serious complications requiring systemic antibiotics 1