A friction blister is a small pocket of fluid that forms in the upper layers of skin caused by continuous rubbing or pressure over time. Friction blisters commonly appear on feet during or after walking long distances, or on hands after using a tool for a long time.
Guidelines
- If a friction blister does not cause serious discomfort, the first aid provider should consider keeping the blister intact. This may decrease the risk of bacteria and infection, compared to draining it (aspiration) or removing the top layer of the blister (deroofing). *
Good practice points
- Friction blisters can lead to an open wound, bleeding or infection, limiting individual mobility. In these situations, the person should stop the activity causing the blister, cover the blister with a sterile dressing and seek medical advice.
- If a friction blister filled with fluid causes serious discomfort or is at risk of self-draining, the first aider should consider draining it. This may reduce the pain associated with the blister. If drained, the blister should be covered with a sterile dressing to ensure the roof attaches to the underlying skin and that the blister does not refill with fluid.
- A small blood-blister can be punctured by a first aid provider; large blood-blisters should be treated by a medical professional.
- Materials like moleskin or commercial hydrocolloid blister-plasters may be applied to minimise additional trauma to the blister and to relieve discomfort.
- Commercial hydrocolloid blister-plasters should not be used at longer distances, because blisters can still come up and the plaster is very difficult to remove from damaged skin.
- Antibiotic ointments are advocated for the immediate treatment of friction blisters only.
Chain of survival behaviours
Prevent and prepare
- Wear dry socks with shoes that fit well.
- Before starting the activity, tape parts of the feet or hands which are likely to rub.
- Carry appropriate dressings if doing an activity likely to cause blisters.
Early recognition
- The person has been doing an activity likely to cause continuous rubbing or pressure for some time.
- A small pocket of fluid can be seen in the upper layers of skin caused by the friction.
- Many blisters will self-drain if hands and feet continue to be used.
First aid steps
1. Wash the blister and surrounding area with clean water and gently pat it dry.
2. If the blister is intact, cover it with moleskin or a blister pad. If the blister has self-drained, clean the wound and cover it with a sterile dressing (see Cuts and grazes). Reinforce the covering by taping if needed.
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SPECIAL CASE
- If the friction blister is intact and causes serious discomfort:
> Clean the skin over and around the blister with (preferably lukewarm) water.
> Using a standard sterile needle, puncture the blister twice at the lower edge of the blister leaving the rest of the blister roof intact.
> Gently push the fluid out of the blister until all the fluid has been removed.
> Clean the skin over and around the blister again with running water, and then gently pat the skin surrounding the blister dry.
> Cover the blister with a sterile dressing (see Cuts and grazes).
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Access help
- Seek medical advice:
> if the blister becomes an open wound or shows signs of infection such as becoming hot and painful.
> if the person has diabetes or their immune system is compromised. In these people, wounds are more likely to become infected or have trouble healing.
Recovery
Monitor the blister over several days to check for signs of infection (such as heat, continuous pain or onset of fever). If these appear, seek medical care immediately.
Education considerations
Facilitation tips
- Include friction blister education for learners planning a wilderness expedition or an endurance activity such as a long-distance walk.
- Emphasise prevention and preparedness as this is the most effective strategy for managing blisters.
- Explore the appropriate dressings that support preparedness for blisters.
- Facilitate learning that helps individuals to recognise blisters.
- Education may also cover the removal of dressings which should, if possible, not damage the blister. Adhesive removal sprays are available in some pharmacies and may make removing dressings easier.
Scientific foundation
Systematic reviews
The Centre of Evidence-Based Practice (CEBaP) developed an evidence summary in 2019 concerning deroofing or aspirating friction blisters. The review identified two experimental studies about blisters due to burns, which provided indirect evidence on the management of friction blisters.
Deroofing or aspiration
There is limited evidence from one non-randomised controlled trial in favour of keeping a blister intact. It was shown that keeping a blister intact resulted in a statistically significant decrease of bacteria (or Staphylococcus aureus) colonisation, compared to aspirating or deroofing a blister.
In addition, there is limited evidence from one randomised controlled trial in favour of aspiration at the level of the subjective pain experience. It was shown that aspiration of large blisters (greater than 10 mm) resulted in a statistically significant decrease of the subjective pain experience, compared to deroofing of large blisters. However, this could not be shown for small blisters.
At the level of infection risk, it was shown that aspiration of blisters resulted in a statistically significant decrease of blister colonisation with Staphylococcus aureus, compared to deroofing of blisters. However, a statistically significant decrease of blister colonisation with bacteria in general or increase of wound healing could not be demonstrated when comparing aspiration with deroofing.
All evidence is of very low certainty and results cannot be considered precise due to limited sample size, low number of events and large variability of results.
Second-skin bandage
In a second evidence summary, no studies were identified on the effectiveness of second skin bandages.
Prevention
A systematic review published in 2017, aimed to determine which strategies were effective in the prevention of friction blisters in the wilderness and outdoor pursuits (running, hiking, marching, etc.). Clinical and methodologic diversity precluded meta-analysis. Despite the high frequency, discomfort and associated cost, there is little high-quality evidence in support of socks, antiperspirants or barriers for the prevention of friction blisters. Moderate confidence in the effect estimate suggests that paper tape may be an effective form of barrier prevention (Worthing et al., 2017).
Non-systematic reviews
Limited research has been conducted to examine different treatment or prevention for friction blisters (Brennan, 2012; Levy, 2006; Lipman, 2014; Knapik, 1995). Most studies have been performed within the military or in athletes with a who all tend to be similar in age and physical activity levels, with a primary focus on the prevention of blisters (Janssen et al., 2018).
Neither (aspiration) nor removing the top layer of a blister (deroofing) is a superior treatment for blisters. However, some objective indicators suggest that draining a blister might be more effective than removing the top layer (Ro et al., 2018).
The existing body of literature addressing friction blisters includes some narrative reviews. Most notable among these narratives is that published by Knapik et al. in 1995, who included a detailed evidence-based review of pathophysiology, the factors influencing blister formation and recovery. 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 a physical activity if necessary. Clinical trials are needed to determine the efficacy of various blister treatment methods. Antibiotic ointments are advocated for the immediate treatment of friction blisters. There is no published evidence that these measures are of any benefit in healing or preventing infection (Knapik, 1995).
The most effective blister management strategy is prevention. Blister prevention starts with an optimally fitting shoe. Also, moist skin is more vulnerable, so the drier the feet, the less chance of blisters. High-quality, dry socks are important (Jagoda, 1981).
Pre-taping the feet with adhesive tape can be used to prevent friction blisters. The success of taping relies on keeping the tape well-adhered to the skin. However, there are no published studies to show these measures work (Richie, 2010). Also, various “best practices” for preventing blisters are recommended by medical professionals, as well as professional and amateur athletes. The choice of tape and taping-method is an individual choice. Surgical paper tape was not found to be particularly protective against blisters in marathoners, although this intervention was well tolerated and had high user satisfaction (Lipman et al., 2014).
Commercial hydrocolloid blister-plasters can be very helpful and come in several sizes and shapes. Apply these according to the instructions. Do not use commercial blister plasters for longer distances, because blisters can still come up and the plaster is very difficult to remove from the damaged skin.
Because the skin provides natural protection against infection, friction blisters on the foot should be left intact if possible. They usually require simple first aid, such as a bandage to protect the blister area. Blisters can, however, lead to increased discomfort, an open wound, bleeding or infection and limit individual mobility. In this situation, first aid providers should focus on further blister management and pain reduction. For example, during the annual Nijmegen Four Days Marches in The Netherlands, the world’s largest multi-day walking event with daily distances ranging from 30 to 50 kilometres (~18 to 30 miles), the need for treatment of friction blisters is very high. In previous years of the Four Days Marches, the number of participants requiring at least a single blister treatment varied between 4000 and 5000, accounting for 10% of the total number of walkers (Janssen et al., 2018).
Although most friction blisters remain uncomplicated, materials like Moleskin may be applied to minimize additional trauma to the blister and to relieve discomfort (Schwartz and Elston, 2019).
Because the pain from a friction blister is caused by pressure from the built-up fluid, draining a fluid-filled blister will immediately reduce the associated pain. Evidence for blister management and pain reduction suggests puncturing a blister and using adhesive surgical tape, like Leukoplast® by BSN Medical. Only one evidence-based study from the Four Day Marches recommends taping the blister and part of the foot (Roos, 1954). The high-quality viscose backing material is hygienic and resistant to tension. The purpose of the bandage is to ensure that the blister roof adheres to the underlying skin and that it does not refill with fluid after drainage. Though puncturing and taping have proved effective in the past, it is time-consuming. In the case of the Four Days Marches or other events like it, this can lead to long wait lines and disrupt the walking rhythm of those taking part in the event (Janssen et al., 2018).
Clean the entire footpad to remove any grease and allow the adhesive plaster to attach better. Blisters can best be disinfected before and after puncturing with povidone-iodine (Betadine®), unless the person is allergic to it or there are other objections. In this case, the use of pink chlorhexidine (0.5% in 70% alcohol) is recommended. Never puncture a blister through a previously laid-out bandage as you cannot see the blister and is it unhygienic (Gonzales de la Guerra and Dallasta, 2013).
When removing the adhesive tape applied on the foot or toe, the blister may damage. The “best practice” to remove old tape bandages is to remove the glue with white spirit on a gauze between the skin and the adhesive plaster. Do not remove the patch from the skin all at once; take it off in sections and support the skin. Make sure the white spirit does not enter the wound or open blister. In addition to the white spirit, various types of “adhesive remover” sprays or tissues are also available. They do not contain alcohol so will not irritate the skin. (Van Romburgh, 2017).
References
Systematic reviews
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summary Friction blisters – Deroofing or aspiration. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summary Friction blisters – Second skin bandage. Available from: https://www.cebap.org/knowledge-dissemination/first-aidevidence-summaries/
Worthing, R.M., Percy, R.L., & Joslin, J.D. (2017). Prevention of Friction Blisters in Outdoor Pursuits: A Systematic Review. Wilderness Environ Med, 28, 139.
Non-systematic reviews
Brennan, F.H. Jr., Jackson, C.R., Olsen, C., & Wilson, C. (2012). Blisters on the battlefield: the prevalence of and factors associated with foot friction blisters during Operation Iraqi Freedom I. Mil. Med., 177, 157.
Gonzales de la Guerra, J.M. & Dallasta, R.M. (2013). Betadine in the care of friction blisters. Treatment protocol in primary health care Revista de Enfermeria, 36(6), 24-31.
Janssen, L., Allard, N.A.E., ten Haaf, D.S.M., van Romburgh, C.P.P., Eijsvogels, T.M.H., & Hopman, M.T.E. (2018). First-Aid Treatment for Friction Blisters: “Walking Into the Right Direction?” Clinical J. Sport Med, 28(1), 37-42.
Jagoda, A., Madden, H., & Hinson, C.A. (1981). Friction blister prevention study in a population of marines. Mil. Med., 146(1), 42-44.
Knapik, J.J. (2014). Prevention of foot blisters. J Spec Oper Med., 14(2), 95-97.
Knapik, J.J., Reynolds, K.L., Duplantis, K.L., & Jones, B.H. (1995). Friction blisters. Pathophysiology, prevention and treatment. Sports Med., 20, 136–147.
Levy, P.D., Hile, D.C., Hile, L.M. (2006). A prospective analysis of the treatment of friction blisters with 2-Octylcyanoacrylate. J Am Podiatr. Med. Assoc., 96(3), 232-7.
Lipman, G.S., Elis, E.J., Waite, B.L., Lissoway, J., Chan, G.K. (2014). A prospective randomized blister prevention trial assessing paper tape in endurance distances (Pre-TAPED). Wilderness Environ. Med., 25(4), 457-461.
Richie, D. (2010). How to manage friction blisters. Podiatry Today, 23(6), 42-48.
Ro, H.S., Shin, J.Y., Sabbagh, M.D., Roh, S.G., Chang, S.C., & Lee, N.H. (2018). Effectiveness of aspiration or deroofing for blister management in patients with burns: A prospective randomized controlled trial. Medicine, 97(17), e0563.
Roos, J. & Setten, van P.H. (1954). De behandeling van wandelblaren. Dutch J Med, 98, 1988–1992. Schwartz, R.A. & Elston, D.M. (2019). Friction blisters Treatment & Management retrieved from https://emedicine.medscape.com/article/1087613-overview
Van Romburgh, C. (ed). (2017). Verdiepingscursus Eerste Hulp bij wandelletsel. Den Haag: Netherlands Red Cross.
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