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Three Part Question

[In adult patients with superficial burn blisters] does [de-roofing the blister] as opposed to simple [aspiration] have better wound outcomes [promote healing, pain management and minimizing infection].

Clinical Scenario

A 25-year-old male presents to the emergency department after burning his hand on a torch at work. He suffered a superficial burn with a large blister to his dorsal hand. You consider the best evidence-based management of the blister.

Search Strategy

Medline 1966-07/24 using PubMed, Cochrane Library (2024), and Embase Classic (1947-1973)
[(exp Blister/ OR Blister$.mp AND Burns.mp) AND (aspiration.mp. OR deroof$.mp. OR debride$.mp. OR drain$.mp OR burns/therapy)] LIMIT to English language.

Search Outcome

16 total articles were found; four clinical trials were identified as both relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gimbel NS, et al. May 1957 USA	Healthy volunteers who had burns induced across the abdomen. Blisters were left intact, deroofed with scissors, or aspirated.	Prospective experimental study	5-day epithelization	No significant differences	Experimental model; small sample size; not randomized or blinded. The generalizability of the data, given the artificial mechanisms of injury, is unclear. Differences in epithelization were mostly small and of unclear clinical significance.
			14-day epithelization	Blisters left healed faster compared with the aspirated and deroofed groups, and was the only group with completely healed wounds at 14 days
Garg R, et al January 2021 Punjab, India	27 patients who presented with minor superficial 2nd degree burns of upper limbs were randomized to leaving blisters intact vs. deroofing.	RCT	Pain severity	Deroofed blisters were more painful (p< 0.001)	Small sample size, small blisters (<0.5 cm), not blinded
			Soakage of dressing	Soakage was comparable in both subsets
			Day to complete healing	Wound healing was less by mean of 1.7 days deroofed blisters compared to intact blisters (p< 0.001)
Ro HS, et al. April 2018 Republic of Korea	40 patients with burn blisters greater than 6-mm were enrolled and randomized into 2 groups: aspiration group and deroofing group.	RCT	Number of days to complete wound healing	Difference was not statistically significant (P=0.96)	Relatively small sample size; potential confounding factors were not adjusted for within the data collection; proper wound management could prevent wound colonization with bacteria; lack of a defined primary outcome measure; and study did not include a group of patients on whom blisters were left intact.
			Scar Assessment Scale	Aspiration scars were rated better at 12 mos. (P=0.03)
			Visual analogue pain score	Difference was not statistically significant (P=0.26)
			Colonization with microorganisms	Lower in the aspirated blisters but not significant (p=0.15)
Swain AH, et al. July 1987 UK	202 patients attending two accident departments for treatment of minor thermal burns to arms and legs. During the first part of the study blisters were left intact for up to 10 days. In the second part blister fluid was aspirated through a single puncture hole.	Prospective clinical trial	Risk of bacterial colonization	Colonization was lower in the intact blisters than in either the aspirated blisters or deroofed burns (P< 0.05)	Not randomized; open-label design; some of the blisters which were aspirated in the second part of the study were actually deroofed; bacterial colonization may simply be a function of proper wound care; and there was no quantification of pain reported by patients.
			Pain in the burn area on 2nd day	Aspiration reduced pain (P<0.05)

Comment(s)

There is a paucity of randomized control trials regarding the best management of burn blisters. Existing studies are poorly designed with conflicting results. Each method has advantages: leaving a blister intact may decrease the risk of infection and reduce pain. De-roofing a blister may promote healing. While aspiration will decrease the risk of large blisters rupturing spontaneously at home and facilitate application of wound dressings.

Clinical Bottom Line

When managing superficial burns there appears to be no method of management that is superior to the other. Clinicians should use clinical judgment in determining whether to leave select burn blisters intact or perform aspiration or debridement.

References

1. Gimbel NS, Kapetansky DI, Weissman F, Pinkus HKB. A Study of Epithelization in Blistered Burns. AMA Arch Surg 1957;74(5):800–803
2. Garg R, Rakesh D, Mittal RK, Kathpal SS, Kaur A, Singh K. Managing blisters in minor burns: Should they be deroofed? Indian Journal of Burns Jan–Dec 2021; 29(1):31-35
3. Ro HS, Shin JY, Sabbagh MD, Roh SG, Chang SC, Lee NH. Effectiveness of aspiration or deroofing for blister management in patients with burns: A prospective randomized controlled trial. Medicine (Baltimore) 2018 Apr;97(17):e0563
4. Swain AH, Azadian BS, Wakeley CJ, Shakespeare PG. Management of blisters in minor burns. Br Med J (Clin Res Ed). 1987 Jul 18;295(6591):181