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    -  Garg R
    -  Rakesh D
    -  Mittal RK
    -  Kathpal SS
    -  Kaur A
    -  Singh K

 
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ORIGINAL ARTICLE
Ahead of print publication
 

Managing blisters in minor burns: Should they be deroofed?


 Department of Plastic and Reconstructive Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission03-Sep-2020
Date of Acceptance18-Mar-2021
Date of Web Publication03-Feb-2022

Correspondence Address:
Devika Rakesh,
N-96 PG Hostel, DMCH, Civil Lines, Tagore Nagar, Ludhiana - 141 001, Punjab
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijb.ijb_25_20

  Abstract 


Introduction: Management of burn blister has always been controversial. The options available are deroofing the blister, aspiration of fluid or leaving the blister intact. There is no set dressing protocol for managing blisters.
Aims and objectives: To compare two treatment modalities i.e. deroofing and keeping the burn blister intact for the optimal management of minor superficial 2nd degree burns .
Material and Methods: This prospective study was done on 27 patients who presented with minor superficial 2nd degree burns of upper limbs. Total of 50 blister wounds were randomly split into two categories of 25 each. One subset of blisters (Category 1) was deroofed and dressed every alternate day with silver alginate dressing. The other subset of blisters was left intact (Category 2) and dressed every alternate day. The parameters assessed and compared were pain at burn site, soakage of dressing and time to complete healing
Statistical Analysis: Student t –test and Chi square (χ2) test . SPSS 21 software
Results: The mean age of patients was 36 years. Category 1 wound patients had more pain (as assessed by Visual Analogue Scale) in comparison to Category 2 wounds. The time to wound healing was less by mean of 1.7days in Category 1 wounds compared to Category 2 wounds. Wound soakage was comparable in both subsets.
Conclusion: De roofing a burn blister results in statistically significant decrease in time to wound healing and is recommended for management of minor superficial 2nd degree burns.


Keywords: Deroofing, superficial burn blister, wound healing



How to cite this URL:
Garg R, Rakesh D, Mittal RK, Kathpal SS, Kaur A, Singh K. Managing blisters in minor burns: Should they be deroofed?. Indian J Burns [Epub ahead of print] [cited 2022 May 24]. Available from: https://www.ijburns.com/preprintarticle.asp?id=337207





  Introduction Top


Plastic surgeons commonly encounter blisters when treating burn patients. The formation of unblemished blisters at the exposed parts of the heat is characteristic of the superficial partial-thickness burn. Burn blisters occur primarily in superficial partial-thickness burns but also may overlay mid-to-deep partial-thickness burns. They are a result of inflammatory changes that occur early in burn injury whereby increased capillary permeability allows edema formation between the epidermis and dermis. Recommended procedures for burn blister management include deroofing, aspiration, and leaving blisters intact.[1],[2] Management of the burn blister in partial-thickness burns remains a controversial topic in burn care. The arguments for the preservation of the burn blister center on the natural biological protection afforded to the wound with the intact blister and the wound healing benefits of blister fluid. The arguments in favor of blister debridement and fluid evacuation focus on the components of blister fluid that are detrimental to wound healing and the infection potential associated with an unroofed blister. The question as to whether burn blisters should be drained or deroofed has long been debated for many years in medical literature, and the optimal treatment of burn blisters is still debatable.

Herein, we compared two modalities, i.e. deroofing and keeping the burn blister intact for the management of minor superficial 2nd degree burns with the aim to identify the optimal treatment modality for these burn blisters.


  Materials and Methods Top


This prospective study involved 27 patients who presented to the Plastic Surgery Outpatient Department (OPD) of Dayanand Medical College and Hospital with minor superficial 2nd degree burns of upper limbs involving <15% of total body surface area, over a period of 1 year from January 2019 to January 2020. Clinical examination revealed blisters and some erythema in varied areas of upper limbs. After obtaining written informed consent from all 27 patients, a total of 50 blister wounds among these patients were randomly split into two categories of 25 each. One subset of blisters (Category 1) was deroofed on the 1st day after snipping the blister and draining the fluid using scissors and forceps, and the devitalized tissue was carefully cut up to (but not including) the margin of the sensate tissue and dressed every alternate day with silver alginate dressing [Figure 1] and [Figure 2]. The other subset of blisters was left intact (Category 2) and dressed every alternate day till the wound epithelized [Figure 3]. Exclusion criteria were as follows:
Figure 1: (a) Burn blisters at presentation (b) Deroofing of the burn blister performed on the 1st day for middle and ring finger and blisters on little and index finger left intact (c) Healing complete by 9th day

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Figure 2: Deroofed skin of a patient from Category 1

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Figure 3: (a) Burn blister at the time of presentation (b) blister left intact and healed by day 9

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  1. Burn blister <0.5 cm and >2.5 cm
  2. Burns covering more than 15% of body surface area
  3. Subjects with severe systemic disease or psychotic disorders
  4. A blister that had already ruptured at the time of the visit or after first aid treatment by another institution.


The pain at burn site during dressings was assessed on days 1, 3, 5, 7, and 9 using Visual analog scale (VAS) the patient was asked to score their level of burn wound pain from 0 to 5, 0 for no pain and 5 for worst pain. The presence of soakage of dressing was compared among the two categories. Finally, time taken for complete wound healing in terms of epithelization of blisters was evaluated.


  Results Top


The mean age of patients in our study was 36 years. Most of the patients in our study were females. 70% sustained burn injuries while working in the kitchen. On pain assessment, 16 patients (64%) in the deroofing group (Category 1) gave a pain score of 4 or more (as assessed by Visual Analog Scale) indicating severe pain. Whereas in Category 2 (intact blister), majority of the patients, i.e. 20 (80%) had a score of 2 or less indicating mild pain [Table 1]. The mean days taken for wound healing in Category 1 patient was 7.24 ± 0.64 days. In majority of the Category 1 cases (88%), the wound healed completely by day 7. The mean time taken for complete wound healing in Category 2 patients was 8.92 ± 0.35 days. The time to wound healing was less by mean of 1.7 days in Category 1 wounds compared to Category 2 wounds which was statistically significant. Complete wound healing was achieved in all the patients in our study. There was no infection reported in any of the cases. 44% of the patients in Category 1 and 40% of patients in Category 2 had wound soakage [Figure 4]. Therefore, wound soakage was comparable in both subsets.
Figure 4: Showing distribution of patients in both categories according to pain severity, day to wound healing, and presence or absence of soakage

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Table 1: Distribution of patients in both categories according to pain severity, day to wound healing, and presence or absence of soakage

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  Discussion Top


Very limited scientific publications are available on managing blisters after burns. Burn blister management remains a controversial subject, and no universal standard of practice has been established among people who deal with burn blisters, even among certified medical burn centers.[3],[4] Sargent[5] described the standards of superficial partial-thickness burns that could be used to devise an evidence-based policy and he discussed clinical applications and conflicting recommendations.

Our exclusion criteria involved burn blister <0.5 cm since blisters smaller than this, do not cause any significant discomfort to the patient and those >2.5 cm are most likely to rupture on their own. Hence, this blister size was found to be apt to be included in the study. Second, our idea to include only minor superficial 2nd degree burns was based on the fact that these were the patients who could be handled as outpatients needing no hospitalization. Deroofing was carried out in our Category 1 patients as an OPD procedure without the need for any local anesthesia since only the devitalized tissue was excised taking care not to encroach upon the surrounding sensate tissue.

Inflammatory mediators within blister fluid contribute to increasing size of the blister as the result of their effects on local microcirculation and subsequent increases in capillary permeability.[6] Rockwell and Ehrlich[7] ascribed worsening wound necrosis to a plasmin inhibitor contained in blister fluid. These findings support the evacuation of blister fluid to preserve microvascular circulation and to prevent the progression of partial-thickness to full-thickness burn. Therefore, we took up this study to evaluate the effectiveness of deroofing burn blisters.

We examined the pain score for the patients in both groups to determine which procedure provided more comfort during dressing. The VAS is an established measure of differences in pain.[8] The patient's pain tended to decrease rapidly from day 3; therefore, we decided that the comparison on day 1 was more objective and meaningful than the subsequent data. The pain score in the deroofing group was significantly higher than in the group where blisters were kept intact during the treatment period particularly during the first 2 dressings. This could be attributed to exposure of sensory nerve endings with loss of epidermal coverage and direct stimulation of these superficial nerves during dressings. Intact blisters may offer a natural method of pain relief with their coverage of underlying cutaneous nerves and be appropriate pain management for small blisters.[5] Having said that, increasing fluid volume within the blister may also contribute to patient discomfort, restriction of movement; therefore, deroofing of large blisters (blisters >6 mm) may in turn enhance patient comfort.[2]

Partial-thickness burns generally heal spontaneously with superficial variations, taking approximately 5–7 days whereas mid-to-deep types require 10–21 days or longer for complete re-epithelization. In our study, the mean days taken for epithelization in Category 1 blisters was 7.24 days and in Category 2 blisters was 8.92 days. The difference between mean time to healing between the two groups was statistically significant P (<0.05). Although patient's age, nutritional status, and comorbidities all contribute to the healing process, treatment of the partial-thickness burn also impacts the rate of healing. A moist wound bed has been shown to facilitate healing largely because epidermal cells migrate more quickly and efficiently in the presence of moisture. Uchinuma et al.[9] report fibroblast growth stimulation and collagen synthesis in the presence of blister fluid and Ono et al.[10] report the presence of cytokines which stimulate keratinocytes and thus healing. The literature is somewhat contradictory on this topic; Garner et al.[11] advocate for blister debridement based on their analysis of blister fluid and its suppression of healing cells whereas Reagan et al.[12] found both proliferative and inhibitory effects of blister fluid on keratinocyte replication.

Infection risk in the superficial to mid-partial-thickness burn is substantially less than that of burns with deeper dermal involvement.[13] It is, therefore, imperative to accurately identify the depth of the burn wound because it correlates with the risk of wound infection and delineates further care decisions. The wound bed of a partial-thickness burn with blister is continuously exposed to the contents contained within the exudate. Blister fluid is known to contain a variety of substances, including electrolytes, enzymes, proteins, and inflammatory mediators such as thromboxanes, prostaglandins, and leukotrienes.[14] The immunosuppressive consequences of blister fluid in terms of lymphocytic and phagocytic suppression and its potential contribution to local wound infection have been explored. Further research has confirmed the adverse effects of blister fluid on local wound immune function. Deficient complement has also been noted in blister fluid.[15] Systemic immune function also may be compromised by the cascade of inflammation occurring locally in the wound, putting patients at higher risk for sepsis.[15] Thus, evacuation of contained fluid may mitigate immunosuppression and improve the patient's ability to defend against infection both locally and systemically.

The advantages of deroofing include removal of nonviable tissue, better assessment of wound bed, relief of pain associated with tense blisters, unrestricted movement across joints, and wound creation in clean conditions. The main disadvantage associated with it is disturbing the biological barrier. Swain et al.[16] in their study evaluated the usefulness of deroofing versus aspiration in the management of blisters and were of the opinion that aspiration should be preferred over deroofing of blisters in most cases because the pain and exposed surfaces associated with deroofing may promote colonization. It is worth noting that increased wound colonization does not always correlate with increased wound infection as other host characteristics factor into the development of an infection. Sibbald et al.[17] suggested the benefits of some degree of bacterial colonization to maintain a floral balance in chronic wounds. However, we did not encounter wound infection in any of the wounds where deroofing was done. In addition, the study by Swain et al. had the disadvantage of lacking randomization. There seems to be a paucity of good clinical evidence for which treatment modality is superior, despite several review articles. The literature regarding blister management in the partial-thickness burn lacks a well-designed comparative trial specifically focused on deroofing versus non-deroofing while using current wound care knowledge and resources. In our opinion, blisters must be deroofed to prevent the mechanical pressure of the blister fluid on underlying tissue and exposure of wound bed to blister fluid that otherwise might suppress local and systemic immune function. Deroofing the blister also assists the clinicians with proper visualization of the wound bed and allows accurate assessment of depth of wound to determine the appropriate treatment. Although many factors are involved in wound healing and reepithelialization, moisture is one of the most important factors. Hydrofibers, alginates, and foam dressings have been found to absorb exudate, keep the wound bed moist, and require fewer dressing changes. After evacuation of blister fluid, the use of dressings like alginates for keeping the moisture intact is advocated as used in our study.

Based on our study, we recommend deroofing of all blisters which hasten the wound healing process without causing a significant increase in the infection rate despite the removal of the mechanical epidermal barrier if a sterile and congenial wound environment is provided by means of appropriate dressings. The main strength of our study is that it is a prospective study with a randomized control design evaluating effectiveness of deroofing the blisters. A limitation of our study was the relatively small sample size. For this reason further larger studies are needed to confirm our findings.


  Conclusion Top


Considerable morbidity is associated with burn wounds that are improperly or haphazardly managed, leading to prolonged need for medical care and unnecessary pain and suffering on the part of the patient. Therefore, there is a need to establish an optimal treatment protocol for the management of blisters in minor superficial 2nd degree burns. Based on our study, we recommend deroofing the burn blister for their management since it reduces the time to wound healing considerably without compromising on the blister vulnerability to infections if appropriate dressing material is used.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arturson G. Mechanism of Injury. Principles and Practice of Burns Management. New York: Churchill Livingstone; 1996. p. 61-82.  Back to cited text no. 1
    
2.
Richard R, Johnson RM. Managing superficial burn wounds. Adv Skin Wound Care 2002;15:246-7.  Back to cited text no. 2
    
3.
Fakhry SM, Alexander J, Smith D, Meyer AA, Peterson HD. Regional and institutional variation in burn care. J Burn Care Rehabil 1995;16:86-90.  Back to cited text no. 3
    
4.
Hill MG, Bowen CC. The treatment of minor burns in rural Alabama emergency departments. J Emerg Nurs 1996;22:570-6.  Back to cited text no. 4
    
5.
Sargent RL. Management of blisters in the partial-thickness burn: An integrative research review. J Burn Care Res 2006;27:66-81.  Back to cited text no. 5
    
6.
Flanagan M, Graham J. Should burn blisters be left intact or debrided? J Wound Care 2001;10:41-5.  Back to cited text no. 6
    
7.
Rockwell WB, Ehrlich HP. Fibrinolysis inhibition in human burn blister fluid. J Burn Care Rehabil 1990;11:1-6.  Back to cited text no. 7
    
8.
Farrar JT, Portenoy RK, Berlin JA, Kinman JL, Strom BL. Defining the clinically important difference in pain outcome measures. Pain 2000;88:287-94.  Back to cited text no. 8
    
9.
Uchinuma E, Koganei Y, Shioya N, Yoshizato K. Biological evaluation of burn blister fluid. Ann Plast Surg 1988;20:225-30.  Back to cited text no. 9
    
10.
Ono I, Gunji H, Zhang JZ, Maruyama K, Kaneko F. A study of cytokines in burn blister fluid related to wound healing. Burns 1995;21:352-5.  Back to cited text no. 10
    
11.
Garner WL, Zuccaro C, Marcelo C, Rodriguez JL, Smith DJ Jr. The effects of burn blister fluid on keratinocyte replication and differentiation. J Burn Care Rehabil 1993;14:127-31.  Back to cited text no. 11
    
12.
Reagan BJ, Staiano-Coico L, LaBruna A, Mathwich M, Finkelstein J, Yurt RW, et al. The effects of burn blister fluid on cultured keratinocytes. J Trauma 1996;40:361-7.  Back to cited text no. 12
    
13.
Karyoute SM, Badran IZ. Tetanus following a burn injury. Burns Incl Therm Inj 1988;14:241-3.  Back to cited text no. 13
    
14.
Heggers JP, Loy GL, Robson MC, Del Beccaro EJ. Histological demonstration of prostaglandins and thromboxanes in burned tissue. J Surg Res 1980;28:110-7.  Back to cited text no. 14
    
15.
Deitch EA, Dobke M, Baxter CR. Failure of local immunity. A potential cause of burn wound sepsis. Arch Surg 1985;120:78-84.  Back to cited text no. 15
    
16.
Swain AH, Azadian BS, Wakeley CJ, Shakespeare PG. Management of blisters in minor burns. Br Med J (Clin Res Ed) 1987;295:181.  Back to cited text no. 16
    
17.
Sibbald RG, Williamson D, Orsted HL, Campbell K, Keast D, Krasner D, Sibbald D. Preparing the wound bed – debridement, bacterial balance, and moisture balance. Ostomy/Wound Manage 2000; 46:14-35.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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