Burns Society of Kenya — Clinical Practice Guideline Adapted from BBA Burn Blister Guidelines | For use in prehospital, emergency, primary and secondary care settings

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WHAT IS A BURN BLISTER?

A burn blister forms when increased capillary permeability causes fluid to accumulate between the epidermis and dermis following a burn injury. Blisters occur primarily in superficial partial thickness burns but may also overlie deeper burns, where they can mask the true wound depth.

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LEAVE INTACT

Small, non-tense blisters smaller than 6 mm

• Serve as a natural biological dressing and provide pain control
• Unlikely to rupture spontaneously or impede healing
• Disturbing these blisters offers no clinical benefit at this stage

Note: In severe or extensive burns, blister management is never the priority. Resuscitation, cooling, and transfer take precedence.

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DEROOF

Large thin-walled blisters (greater than 6 mm)

• Most commonly occur on hair-bearing skin surfaces
• High likelihood of spontaneous rupture, which significantly increases infection risk
• Deroofing in a controlled setting is safer than leaving them to rupture uncontrolled

Thick-walled blisters over fingertips, palms, and soles

• Cause significant discomfort and restrict movement
• Cut a sizeable window to drain fluid and allow wound bed assessment
• Full deroofing may not be necessary — a drainage window is an acceptable alternative

Already ruptured blisters and loose skin

• Remove all non-viable, necrotic, and potentially contaminated tissue from the wound bed
• Leaving devitalised tissue increases infection risk and delays healing

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WHY DEROOF? — CLINICAL RATIONALE

Deroofing where indicated achieves the following:

• Allows direct visualisation of the wound bed for accurate burn depth assessment, including capillary refill and sensation testing
• Removes non-viable tissue, promoting faster healing and reducing scarring
• Evacuates blister fluid, which has been shown to suppress local and systemic immune function
• Reduces infection risk from uncontrolled rupture and prolonged presence of devitalised tissue
• Relieves pressure on the wound microcirculation, preventing burn depth progression
• Enables joint movement, reducing the risk of early contracture formation
• Improves the effectiveness of topical wound therapy

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QUICK REFERENCE

Blister Type	Action
Small, non-tense, less than 6 mm	Leave intact
Large, thin-walled, greater than 6 mm	Deroof
Thick-walled on palms, fingertips, soles	Cut drainage window
Ruptured or loose skin present	Debride and remove non-viable tissue
Severe or extensive burns	Do not prioritise blister management — transfer first

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IMPORTANT REMINDERS FOR KENYAN CLINICAL SETTINGS

• All burn injuries meeting national referral criteria should be discussed with the nearest Burns Service before and during management
• Do not attempt blister deroofing in the field without a clean environment, appropriate instruments, and adequate analgesia
• In resource-limited settings, covering an intact blister with a clean non-adherent dressing and arranging transfer is a safe temporising measure
• Document blister size, location, wall thickness, and whether fluid is clear or haemorrhagic — haemorrhagic blister fluid may indicate deeper burn injury

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Burns Society of Kenya Adapted from: BBA Clinical Practice Guideline for Management of Burn Blisters | London and South East of England Burn Network

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