Management of burns blisters

Management of burns blisters

Report by Jonathan Shaw, Specialist Registrar in Emergency Medicine

Search checked by Colin Dibble, Specialist Registrar in Emergency Medicine

Stepping Hill Hospital, Stockport

A short cut review was carried out to establish whether leaving intact, deroofing, or aspirating the blisters of partial thickness burns best minimised infection and promoted healing. In total, 153 papers were found using the reported searches, of which one presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this best paper are tabulated. It is concluded that the evidence remains poor, but that leaving the blister intact seems to reduce infection rates and should therefore be the default option.

Clinical scenario

A 30 year old chef attends the emergency department, having sustained burns to his forearm from hot fat. Clinical examination reveals blistering to the area and some erythema. You are not sure whether to leave, aspirate, or completely deroof the blisters, and wonder if there is any research to point you in the right direction.

Three‐part question

In [adults with partial thickness burns] is [de‐roofing or aspirating the blisters better than conservative management] in [minimising infection and promoting healing]?

Search strategy

Ovid MEDLINE 1966 to May week 2 2006, EMBASE 1980 to week 20 2006, CINAHL 1982 to May week 2 2006 using multifile searching: [exp Blister/OR blister$.mp. OR burn blister.mp.] AND [aspiration.mp. OR deroof$.mp. OR debride$.mp. OR drain$.mp.].

The Cochrane Library Issue 2 2006: blister [MeSH]: 64 identified, none relevant.

Outcome

There were 153 papers identified in Medline of which one was relevant.

Table 2.

Author, country, date	Patient group	Study type	Outcomes	Key results	Study weaknesses
Swain AH et al, 1987, UK	202 patients with partial thickness thermal burns. Left intact v aspirated v exposed	Controlled trial	Infection rates at 10 days	15% v 73% v 78% (p<0.05)	Small numbers. Randomisation unclear and numbers inconsistent
			Pain reduction (aspiration v deroofing)	34% v 0%
			Pain increase (aspiration v deroofing)	19% v 43%

Comments

There seems to be a paucity of good clinical evidence related to this subject, despite several review articles. The sole paper found involved a small sample, but showed infection rates to be higher if blisters are aspirated or deroofed, and that pain scores were higher in the group that underwent deroofing.

Clinical bottom line

Based on the current available evidence, blisters should, wherever possible, be left intact to reduce the risk of infection, but if anatomical position necessitates intervention for functional purposes, aspiration appears to result in less pain than deroofing.