Management of Fluid-Filled Burn Blisters
Leave the blister intact, pierce it at the base with a sterile needle to drain the fluid while keeping the overlying skin in place as a biological dressing, then apply a greasy emollient and cover with a non-adherent dressing. 1
Immediate Blister Management Algorithm
Step 1: Initial Assessment and Pain Control
- Provide adequate analgesia before starting any blister care, as patients commonly report pain or burning sensations during the procedure 2, 1
- Consider over-the-counter medications like acetaminophen or NSAIDs for pain management 1, 3
Step 2: Blister Drainage Technique
- Gently cleanse the blister with warmed sterile water, saline, or dilute chlorhexidine (1:5000) using an antimicrobial solution 2, 1
- Pierce the blister at its base with a sterile needle, with the bevel facing up 2
- Select a drainage site where gravity will facilitate fluid drainage and discourage refilling 2
- Gently apply pressure with sterile gauze to facilitate drainage and absorb fluid 2
- For large blisters, use a larger needle and pierce multiple times to ensure adequate drainage 2
Step 3: Critical - Do NOT Deroof the Blister
- Never completely remove the overlying skin (deroof), as it acts as a natural biological dressing that protects the wound, reduces pain, and decreases infection risk 2, 1
- The blister roof should remain in place after drainage 2
Step 4: Post-Drainage Wound Care
- After fluid drainage, gently cleanse again with antimicrobial solution 2
- Apply a greasy emollient such as 50% white soft paraffin with 50% liquid paraffin over the entire burn surface, including the drained blister 2, 1
- This emollient supports barrier function, reduces water loss, encourages re-epithelialization, and significantly reduces complications including hypertrophic scarring 2, 1
- Cover with a non-adherent dressing such as Mepitel or Telfa directly over the emollient 1
- Apply a secondary foam or burn dressing to collect exudate 1
Infection Prevention Strategy
What NOT to Do
- Do not apply topical antibiotics routinely to uninfected burn wounds, as this promotes antimicrobial resistance without reducing infection or mortality 1, 3
- Reserve topical antimicrobial agents only for sloughy or obviously infected areas 1, 3
- Silver sulfadiazine should be avoided on superficial burns as it may delay healing and is associated with increased infection rates and longer hospital stays 3
When to Use Antimicrobials
- Apply topical antimicrobials only if clinical signs of infection develop: increasing pain, redness, swelling, purulent discharge, or systemic signs like fever 1
- Consider silver-containing products for infected areas based on local microbiological advice 1
Critical Pitfalls to Avoid
- Never apply ice directly to burns, as it causes additional tissue ischemia and damage 1, 3
- Never completely unroof blisters, as it significantly increases infection risk 1
- Never apply butter, oil, or home remedies to burns, as this increases infection risk and delays healing 1
- Never use routine topical antibiotics on uninfected wounds 1, 3
When to Refer to Specialist Care
Immediate referral to a burn center is mandatory for: 1, 3
- Burns involving face, hands, feet, or genitals
- Burns greater than 10% total body surface area in adults or 5% in children
- All full-thickness burns
- Signs of inhalation injury (facial burns, difficulty breathing, soot around nose/mouth)
- Bilateral hand involvement
- Signs of systemic infection or sepsis
Follow-Up Monitoring
- Change dressings using aseptic technique and monitor for signs of infection at each change 2, 1
- Document the number and location of new blisters on a daily blister chart 2
- Re-epithelialization typically occurs within days to weeks depending on burn depth 1
- Watch for increasing pain, as this may indicate infection or burn wound conversion requiring medical evaluation 1