What is the best way to manage a blister in a patient with a burn, considering potential complications such as infection and impaired wound healing, especially in those with underlying medical conditions like diabetes?

Management of Burn Blisters

Leave burn blisters intact and cover them loosely with a sterile or clean non-adherent dressing—this approach reduces pain, protects against infection, and promotes faster healing. 1

Immediate First Aid: Cool the Burn First

Before addressing the blister itself, immediately cool the burn with tap water at 15-25°C for at least 5-20 minutes until pain is relieved, ideally within 30 minutes of injury. 1, 2 This critical step reduces pain, edema, burn depth, speeds healing, and may eliminate the need for surgical grafting. 2

Critical pitfall: Never apply ice or ice water directly to burns—this causes tissue ischemia and worsens tissue damage. 1, 2

Remove jewelry before swelling occurs to prevent vascular compromise. 1

Blister Management Protocol

For Intact Blisters (Preferred Approach)

The intact blister functions as a natural biological dressing that provides a sterile barrier, protects against infection, and significantly decreases pain compared to removal. 1

Step-by-step management:

• Gently irrigate the burn area with warmed sterile water, saline, or dilute chlorhexidine (1:5000) to remove debris without rupturing the blister. 1, 2

• Leave the blister completely intact unless it is tense and causing significant discomfort—in that case only, pierce the blister at the base with a sterile needle to drain fluid while preserving the blister roof. 1

• Apply a greasy emollient such as 50% white soft paraffin with 50% liquid paraffin, petrolatum, or petrolatum-based antibiotic ointment over the entire burn surface including the intact blister. 1, 2 This significantly reduces complications including hypertrophic scarring compared to dry dressings. 2

• Cover loosely with a clean, non-adherent dressing (such as Mepitel or Telfa) with a secondary foam or burn dressing to collect exudate. 1, 2

Do NOT routinely unroof or puncture blisters—this significantly increases infection risk and pain. 1, 2

For Already Ruptured Blisters

• Leave the overlying skin in place as a biological dressing—it protects the wound, reduces pain, and decreases infection risk. 2

• Gently clean with warmed sterile water or saline. 2

• Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the area. 2

• Cover with non-adherent dressing. 2

Infection Prevention: When to Use Antimicrobials

Do NOT apply topical antibiotics routinely to all burn wounds or intact blisters. 1, 2 This promotes antimicrobial resistance without benefit. 2

Reserve topical antimicrobials (such as silver sulfadiazine) only for:

• Sloughy areas with clinical signs of infection 1, 2
• Areas with purulent drainage, foul odor, or increasing erythema 1
• Never apply to intact blisters or clean healing wounds 1

Monitor daily for infection signs: increasing pain, redness, swelling, purulent discharge, fever, or systemic signs. 2 Take bacterial swabs from suspicious areas. 1

Use systemic antibiotics only if local or systemic signs of infection develop—not prophylactically. 1

Pain Management

Provide adequate analgesia with over-the-counter acetaminophen or NSAIDs for most burns. 1, 2 Consider short-acting opioids for more severe pain during dressing changes. 2

Mandatory Specialist Referral Criteria

Immediately refer to a burn center for: 1, 2

• Burns involving face, hands, feet, or genitals (risk of permanent disability)
• Burns >10% total body surface area in adults or >5% in children
• All full-thickness burns
• Signs of inhalation injury (facial burns, difficulty breathing, singed nasal hairs, soot around nose/mouth)
• Bilateral hand involvement
• Any signs of systemic infection or sepsis

Additional Critical Pitfalls to Avoid

• Never apply butter, oil, or home remedies—this increases infection risk and delays healing. 2
• Never delay cooling; it must be done within 30 minutes of injury for maximum benefit. 1
• Never cool large burns without ability to monitor core temperature due to hypothermia risk, especially in children. 1
• Never use prolonged silver sulfadiazine on superficial burns as it may delay healing. 2

Follow-Up Care

Re-evaluate frequently for signs of infection at each dressing change. 1 Continue treatment until satisfactory healing occurs or the burn site is ready for grafting. 3 Re-epithelialization typically occurs within days to weeks depending on burn depth. 2