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PubMed1995

Friction blisters. Pathophysiology, prevention and treatment.

Blisters occur frequently, especially in vigorously active populations. Studies using respective rubbing techniques show that blisters result from frictional forces that mechanically separate epidermal cells at level of the stratum spinosum. Hydrostatic pressure causes the area of the separation to fill with a fluid that is similar in composition to plasma but has a lower protein level. About 6 hours after formation of the blister, cells in the blister base begin to take amino acids and nucleosides; at 24 hours, there is high mitotic activity in the basal cells; at 48 and 120 hours, new stratum granulosum and stratum corneum, respectively, can be seen. The magnitude of frictional forces (Ff) and the number of times that an object cycles across the skin determine the probability of blister development - the higher the Ff, the fewer the cycles necessary to produce a blister. Moist skin increases Ff, but very dry or very wet skin necessary to produce a blister. Moist skin increases Ff, but very dry or very wet skin decreases Ff. Blisters are more likely in skin areas that have a thick horny layer held tightly to underlying structures (e.g. palms of the hands or soles of the feet). More vigorous activity and the carrying of heavy loads during locomotion both appear to increase the likelihood of foot blisters. Antiperspirants with emollients and drying powders applied to the foot do not appear to decrease the probability of friction blisters. There is some evidence that foot blister incidence can be reduced by closed cell neoprene insoles. Wearing foot socks composed of acrylic results in fewer foot blisters in runners. A thin polyester sock, combined with a thick wool or polypropylene sock that maintains its bulk when exposed to sweat and compression reduces blister incidence in Marine recruits. Recent exposure of the skin to repeated low intensity Ff results in a number of adaptations including cellular proliferation and epidermal thickening, which may reduce the likelihood of blisters. More well-designed studies are necessary to determine which prevention strategies actually decrease blister probability. Clinical experience suggests draining intact blisters and maintaining the blister roof results in the least patient discomfort and may reduce the possibility of secondary infection. Treating deroofed blisters with hydrocolloid dressings provides pain relief and may allow patients to continue physical activity if necessary. There is no evidence that antibiotics influence blister healing. Clinical trials are needed to determine the efficacy of various blister treatment methods.(ABSTRACT TRUNCATED AT 250 WORDS)

Blister↗
PubMed2006

Blisters associated with lower-extremity fracture: results of a prospective treatment protocol.

OBJECTIVES: To evaluate patient outcomes after treatment of lower-extremity fractures associated with blister formation and to assess complications after soft-tissue treatment using a prospective protocol. DESIGN: Retrospective evaluation of prospectively collected data. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Between September 1999 and September 2003, 47 patients who had sustained a closed lower-extremity fracture with early development of fracture blisters in the zone of injury were followed. Blisters were characterized as either avoidable or unavoidable with respect to surgical incisions, and characteristics such as number, size, blood filled or clear filled, and the presence of an intact roof were documented. INTERVENTION: All blisters were unroofed, and antibiotic cream (silver sulfadiazine, Silvadene, King Pharmaceuticals Inc.) was applied twice daily until the blister bed had re-epithelialized. MAIN OUTCOME MEASUREMENTS: Fracture union and the development of wound or skin complications. Patient satisfaction with the cosmetic outcome of the treatment regimen was assessed through telephone survey at 23-month minimum follow-up. RESULTS: Twenty-eight patients presented with a single blister, and 19 had multiple blisters. Blister size averaged 9.7 cm. Twenty-two patients had blood-filled blisters, 20 had clear-filled blisters, and five had a combination of the two. Fracture patterns included 17 ankle fractures (OTA 44), 13 tibial plateau fractures (OTA 41), five tibial-shaft fractures (OTA 42), eight calcaneus fractures (OTA 45), and four pilon fractures (OTA 43). Mean delay in definitive surgical care was 7.7 days (range 0 to 20 days). The average delay of surgery for ankle fractures was 6 days (range 0 to 18 days), which was significantly less than the delay for calcaneus fractures (12 days, range 4 to 19 days, P < 0.02) and tibial plateau fractures (11 days, range 0 to 20 days, P < 0.02). Thirty-seven of the 45 patients (82.3%) available for follow-up at a mean of 27 weeks (range 14 to 35) had an uncomplicated postoperative course, and fracture union was achieved in 43 of 45 cases (95.6%). The soft-tissue complication rate associated with the standardized treatment regimen was 13.3% (6/45 cases), with three cases of minor soft-tissue breakdown, one superficial infection, and two major complications directly related to the presence of fracture blisters. Both major complications involved full-thickness skin breakdown occurring directly at the base of fracture blisters in patients with diabetes. The skin breakdown required further surgery in both cases. Including the two patients who developed nonunion, the overall complication rate for the treatment cohort was 17.7% (8/45 cases). At a mean follow-up of 51.9 months (range 23 to 73), three patients in the cohort had expired. Of the 42 patients available for evaluation, 28 patients (67%) were reachable for a telephone survey to assess satisfaction with the outcome of the fracture and soft-tissue management. Patients rated their satisfaction with the cosmetic appearance of their lower extremities after the standardized treatment regimen on a scale of 1 to 10 (with 10 representing very satisfied), with a mean of 9.07 (range 5 to 10). Six patients reported scarring at the sites of previous fracture blisters, all of which occurred after blistering of the blood-filled subtype. The presence of scarring significantly decreased patient satisfaction with cosmesis and overall treatment (P < 0.0001 and P < 0.01, respectively). CONCLUSIONS: Treatment of fracture blisters with a silver sulfadiazine (Silvadene) regimen proved to be successful in minimizing soft-tissue complications by promoting re-epithelialization in all nondiabetic patients. At long-term follow-up, patients were generally satisfied with the cosmetic outcome of the treatment regimen. Postoperative scarring, which was more common with blood-filled blisters, significantly impacted patient satisfaction. We urge caution when planning to make a surgical incision around an area of both full-thickness (blood-filled) and partial-thickness (clear-filled) fracture blisters in diabetic patients because the zone of injury might extend beyond the borders of the fracture blister.

Adult↗
PubMed1994

Fracture blisters.

A clinical and histological study was performed on fracture blisters found in association with 13 surgically treated ankle fractures. The timing of surgery was dependent upon soft tissue swelling; the status of the blister did not affect this aspect of the decision making process. The average time from injury to surgery was 2.1 days (range, 1-3 days). At the time of surgery all blisters were intact. Skin biopsies were obtained from the edge of the incision in proximity to the blister, and from the bed of the blister when the incision was made through the blister. Clinically, 2 blister types were identified: (1) clear fluid filled, and (2) blood filled. Histologically, both blister types demonstrated a cleavage injury at the dermoepidermal junction. However, the dermis of the clear fluid filled blister retained occasional epithelial cells, while the dermis of blood filled blisters was completely devoid of epidermis. Minimal to no evidence of dermal injury was found in histologic sections from the blister beds or from the skin in close proximity to blisters. All incisions made through and around skin blisters went on to heal without evidence of infection or wound breakdown. Delayed wound healing occurred in 1 patient in whom an incision was placed through a blood filled blister. The blood filled blister appears to represent a slightly deeper injury than the clear fluid blister and had a higher risk of poor healing of surgical incisions.

Adult↗
PubMed1999

Suction blister formation in skin after acute and repeated mast cell degranulation.

Mast cells and their proteases are thought to participate in the development of skin blisters in various pathological conditions. In this study, suction blistering was used as an experimental model to evaluate the significance of mast cells in blister formation after pre-treatment of normal skin with intradermal injections of 100 microg/ml compound 48/80 (a mast cell degranulator) or with 0.1% capsaicin cream. Tryptic and chymotryptic enzyme activities in blister fluids were measured with sensitive p-nitroanilide substrates. Repeated injections of compound 48/80 once a day on 3 or 5 consecutive days or capsaicin applications 3 times a day for 7 or 10 days were used to induce mast cell degranulation and inflammation in normal skin. Both treatments ultimately led to decreased wheal and erythema reactions before suction blistering, but neither treatment affected the size or formation rate of suction blisters. No suction blister fluids had detectable levels of chymotryptic activity, but blister fluids from bullous pemphigoid, herpes zoster and insect bullous eruption, used as the control, revealed clear chymotryptic activity. In addition, tryptic activity in suction blister fluids was not significantly altered after compound 48/80 and capsaicin pre-treatments. However, if the wheal reaction was induced immediately before suction blistering, a significantly increased rate in blister formation together with increased tryptic activity was found, but, unexpectedly, no chymotryptic activity could be detected in blister fluids. The results show that repeated mast cell degranulation in normal skin has no effect on the formation rate of suction blisters, which developed more rapidly on acutely whealing skin. This is probably due to skin oedema rather than mast cell proteases, since no chymotryptic activity was detected in suction blisters where tryptic activity exhibited high individual variation.

Adult↗