How should a friction or mild‑burn blister be managed, including dressing, drainage, analgesia, infection monitoring, and indications for referral?

Blister Management

Initial Management Decision

For friction or mild-burn blisters, leave intact blisters in place unless they are pressure-painful or interfere with function, in which case pierce at the base with a sterile needle to drain while preserving the blister roof as a biological dressing. 1, 2, 3

---

Blister Drainage Technique (When Indicated)

Pierce pressure-painful blisters using the following method:

• Use a sterile needle with the bevel facing up, selecting a site at the base where gravity will assist drainage and discourage refilling 1, 2
• Apply gentle pressure with sterile gauze swabs to facilitate complete fluid drainage and absorption 1, 2
• For large blisters, use a larger needle and pierce multiple times to ensure adequate drainage 1
• Never deroof the blister—the roof acts as a natural biological dressing that reduces infection risk and promotes re-epithelialization 1, 2, 3

---

Wound Care After Drainage or Rupture

Cleanse and dress all blisters systematically:

• Gently cleanse with antimicrobial solution (such as dilute chlorhexidine) before and after drainage, taking care not to cause further trauma 1, 2
• Apply a bland petrolatum-based emollient (50% white soft paraffin with 50% liquid paraffin) to support barrier function, reduce water loss, and encourage re-epithelialization 1, 2, 4
• Cover with a non-adherent dressing secured with soft elasticated bandage or gauze (avoid tape) 1, 2, 4
• Change dressings using aseptic technique 1, 2, 4

For ruptured blisters without infection signs: Leave any remaining blister roof in place as biological coverage 2, 3

For ruptured blisters with clinical infection signs: Remove the blister roof entirely, obtain bacterial cultures, and perform debridement if necrotic tissue is present 4, 3

---

Analgesia

Provide pain relief proactively:

• Offer analgesia (acetaminophen or NSAIDs) before starting blister care, as many patients report burning or pain during the procedure 1, 4
• Maintain background analgesia and provide additional short-term boosts for dressing changes 1, 4
• Consider pain team consultation for complex pain management 1

---

Infection Monitoring

Monitor daily for infection signs and intervene promptly:

• Perform daily assessment for worsening erythema, purulent discharge, increased pain, odor, fever, or systemic symptoms 1, 2, 4
• Daily washing with antibacterial products decreases bacterial colonization 1, 4
• Obtain bacterial and viral cultures from erosions showing clinical infection signs 1, 2, 4
• Apply topical antimicrobials (such as silver-based products) only to clinically infected areas and for short durations—not prophylactically 1, 4
• Initiate systemic antibiotics promptly if there are signs of spreading cellulitis, systemic infection, or sepsis 1, 2

---

Documentation and Follow-Up

Track blister progression systematically:

• Document daily on a blister chart the number, size, and location of new blisters to map disease progress 1, 2, 5
• Re-evaluate within 24–48 hours if managed as outpatient to ensure appropriate response 2

---

Indications for Referral

Refer urgently in the following situations:

• Non-healing single blister without clear etiology—consider necrotizing fasciitis, autoimmune bullous disease, or vascular insufficiency 2
• Atypical presentation or suspected autoimmune disease—obtain skin biopsy for histopathology and direct immunofluorescence 2
• Blisters covering >10% body surface area—consider dermatology consultation 4
• Blisters covering >30% body surface area—immediate hospitalization required 4
• Complex pain management or signs of systemic infection/sepsis 1, 4

---

Common Pitfalls to Avoid

• Do not routinely deroof intact blisters—the roof provides optimal biological coverage 1, 2, 3
• Do not apply topical antimicrobials prophylactically to all blisters—reserve for clinically infected areas to avoid resistance 1, 4
• Do not delay systemic antibiotics when infection signs appear—rapid progression to sepsis can occur 1, 4
• Do not assume simple friction blisters in high-risk populations (bedridden, immunocompromised)—treat as potential pressure ulcers or autoimmune disease 4