What is the best management approach for a patient with a superficial burn and blister?

Management of Superficial Burns with Blisters

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

Immediate Initial Management

Cool the Burn First

• Apply cold tap water (15-25°C) immediately to the burn and continue cooling at least until pain is relieved, ideally within 30 minutes of injury 1, 2
• Cooling reduces pain, edema, and depth of injury while speeding healing and potentially reducing the need for surgical excision and grafting 1
• Never apply ice directly to the burn—this causes tissue ischemia and additional tissue damage 1, 2
• For large burns, avoid prolonged cooling due to hypothermia risk, especially in children 2

Remove Constrictive Items

• Remove jewelry before swelling occurs to prevent vascular compromise 2

Blister Management Protocol

Keep Blisters Intact

• Do not puncture, unroof, or completely remove burn blisters 1, 2, 3
• The intact blister acts as a natural biological dressing that provides a sterile barrier protecting against infection and contamination 2
• Keeping blisters intact significantly decreases pain compared to debriding 2
• Multiple studies demonstrate better healing outcomes when blisters remain intact 2

Exception: Tense, Painful Blisters

• If a blister is tense and causing significant discomfort, pierce it at the base with a sterile needle to drain fluid while preserving the blister roof 2, 3
• After drainage, leave the blister roof intact as it continues to serve as a biological dressing 2, 3

Wound Care After Cooling

Cleansing

• Gently irrigate the burn with warmed sterile water, saline, or dilute chlorhexidine (1:5000) 2, 3
• Ensure no foreign matter remains in the wound 1

Topical Application

• Apply a greasy emollient such as 50% white soft paraffin with 50% liquid paraffin over the entire burn surface, including intact blisters 2, 3
• Alternatively, apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera 2, 4, 5
• Apply to a thickness of approximately one-sixteenth of an inch 4

Dressing Selection

• Cover loosely with a sterile or clean non-adherent dressing (such as Mepitel or Telfa) 1, 2, 3
• The dressing protects the wound while maintaining the natural biological barrier 2
• Occlusive dressings can provide faster healing and are often more cost-effective than traditional treatments 4

Antimicrobial Management

When NOT to Use Topical Antimicrobials

• Do not apply topical antimicrobials like silver sulfadiazine to intact blisters or the entire burn surface 2, 3
• Prophylactic systemic antibiotics are not indicated and may increase bacterial resistance 5

When TO Use Topical Antimicrobials

• Apply topical antimicrobials (such as silver sulfadiazine) only to sloughy areas or areas with clinical signs of infection 2, 3
• Use systemic antibiotics only if there are local or systemic signs of infection, not prophylactically 2

Infection Surveillance

• Monitor daily for clinical signs of infection: increasing erythema, purulent drainage, foul odor, or systemic signs 2
• Take bacterial swabs from sloughy or crusted areas if infection is suspected 2

Pain Management

• Use over-the-counter analgesics such as acetaminophen or NSAIDs for pain control 2, 3

Critical Indications for Immediate Burn Center Referral

Anatomic Location

• Burns involving the face, hands, feet, or genitals require specialized burn center care due to high risk of permanent disability 2, 3
• This applies regardless of burn size or apparent depth 2, 3

Burn Size

• Burns greater than 10% total body surface area (5% in children) require intravenous fluid resuscitation and specialized treatment 2

Inhalation Injury

• Seek immediate EMS activation for signs of inhalation injury: facial burns, difficulty breathing, singed nasal hairs, or soot around nose/mouth 2

High-Risk Populations

• Patients with diabetes mellitus are at increased risk of complications and infection—consider early referral to a burn center 5

Common Pitfalls to Avoid

• Do not delay cooling—it should be done as soon as possible, ideally within 30 minutes of injury 2
• Do not apply ice or ice water directly to burns 1, 2, 3
• Do not puncture or unroof blisters in the first aid setting—this significantly increases infection risk 1, 2, 3
• Do not cool large burns without ability to monitor core temperature due to hypothermia risk 2
• Do not apply topical antimicrobials prophylactically to intact blisters 2, 3

Follow-Up Care

• Reevaluate patients frequently after burn injury 4
• Continue treatment until satisfactory healing has occurred or the burn site is ready for grafting 6
• Be aware that pruritus, hypertrophic scarring, and permanent hyperpigmentation are long-term complications of partial-thickness burns 5