from uptodate Friction blisters
MANAGEMENT — 摩擦引起的水泡在摩擦解除之後通常會自然痊癒. 治療重點在於減少症狀. 降低感染率.
Friction blisters can heal spontaneously when the frictional forces are removed. Interventions are focused on reducing symptoms and minimizing risk for infection.
Symptomatic blisters — 有症狀或限制活動的水泡建議引流, 臨床經驗建議維持水泡頂部完整的引流, 能減輕疼痛降低感染率.
Drainage is suggested for painful blisters and blisters that cause functional limitations. Clinical experience suggests that a drainage procedure that maintains the blister roof minimizes discomfort and may also reduce risk for secondary infection.
水泡引流是相當簡單的步驟, 病患也可以自己做. 先將水泡表面用酒精消毒乾淨, 使用消毒的針穿刺, 對於大的水泡, 可能需穿刺多次. 之後輕微加壓幫助液體流出, 但要維持水泡頂部完整. 讓水泡塌陷貼平, 形同敷料的效果, 如果沒有感染並不需要擦抗生素藥膏. 也不需要口服抗生素.
Blister drainage is a relatively simple procedure that may be performed by a clinician or the patient at home. The blister surface should be cleansed with alcohol. A sterile needle is used to puncture the blister. For large blisters, performing more than one puncture helps to remove blister fluid easily. Light pressure can be applied to aid with removal of the fluid. The blister roof should be allowed to collapse over the blister site to serve as a biologic dressing. Topical or oral antibiotic therapy is not necessary in the absence of infection.
Asymptomatic blisters —無症狀的水泡 , 沒有造成功能限制, 可以讓它保持完整, 會自然吸收. 完整的水泡有助於上皮細胞生長過程維持在無菌狀態, 減少感染率, 在癒合過程如果無法避免外傷, 可使用貼布或敷料保護水泡.
Nonpainful, nonexpanding blisters that do not cause functional limitations may be left intact and allowed to resolve spontaneously. The advantage of an intact blister is maintenance of a sterile environment during re-epithelialization, minimizing the risk for infection. A bandage or other protective dressing can help to protect blisters located in sites where additional trauma cannot be avoided during healing.
Wound care — 傷口照顧. 破裂的水泡應每天溫和的清潔, 以乾淨乾的敷料覆蓋, 避免再次外傷或感染, 如果沒有感染跡象, 不需要移除水泡的皮, 如果有感染跡象則需移除. Ruptured blister sites should be gently cleansed daily and covered with a clean, dry dressing to protect the healing area from trauma and infection. Blister roofs should only be debrided if there is sign of infection.
如果局部出現紅腫化膿, 代表感染跡象, 應給予局部或口服抗生素治療. 治療之前可做細菌培養.
Patients with clinical signs of infection (eg, worsening erythema and purulence) should receive appropriate topical or systemic antibiotic therapy. A culture can be performed prior to treatment to identify the causative organism.
如果病患仍需維持活動, 會刺激水泡部位, 可貼上含凝膠的貼布, 提供襯墊的作用, 有助於減輕疼痛, 此外, 有案例報告使用組織膠能讓病患重新恢復日常活動 (但2014年WMS的建議則說無效) When patients must continue physical activity that will irritate the blister site, application of a hydrocolloid dressing can provide a cushioning effect and may help to reduce discomfort during activity. In addition, a case report describes use of 2-octyl cyanoacrylate on hand blister wounds for the successful return to work-related activity [9]. (See "Minor wound repair with tissue adhesives (cyanoacrylates)".)
PREVENTION — 如何預防水泡, 主要是降低局部摩擦, 找出形成水泡的原因, 例如濕氣, 流汗, 熱, 皮膚接觸的東西. 對於運動員, 預防措施更為重要, 因為容易復發. Measures that reduce frictional forces on the skin are the mainstay of prevention. Factors contributing to blister formation should be reviewed to identify helpful interventions, including the inciting activity, potential exacerbating factors (eg, moisture, sweating, heat), and the objects that were in contact with the skin. Preventive measures are particularly important for individuals whose occupations or athletic activities are associated with high risk for recurrent episodes of friction blisters.
Examples of measures to minimize skin friction include: 降低皮膚摩擦的方式包括
●Alter the inciting activity (eg, adjust technique, discontinue activity) 改變活動方式. 減少活動.
●Ensure proper fit of shoes or other gear that contact skin during the inciting activity (eg, foot does not slide within the shoe during activity) 穿合腳的鞋. 使用合適的腳步裝備. 讓足部不會在裡面滑動.
●Reduce moisture in the affected area during activity (eg, treatment of hyperhidrosis, use of absorptive socks or clothing) 減少水泡產生部位活動中的濕氣. 例如使用吸汗襪. 衣服.
因缺乏品質良好的研究, 一些號稱能減少水泡生成的商品是否有效仍存疑. 有些方式有文獻支持, 例如使用紙膠. 厚丙烯酸樹脂襪. 厚羊毛襪, 加上薄的人工纖維內襯. 止汗劑. 特殊鞋墊提供緩衝減少皮膚剪力. 但這些商品是否有效. 因研究資料方法有問題或研究結果正反都有. 所以無法得到結論. 此外. 止汗劑可能造成皮膚刺激.
Despite the common occurrence of friction blisters, high-quality trials are lacking, and the value of products to reduce frictional force on the skin and protect from blistering remain uncertain. There is some support in the literature for interventions such as paper tape, thick-padded acrylic socks, padded wool socks combined with a synthetic inner liner, antiperspirants 止汗劑, and special insoles that provide cushioning that reduces shear forces on the skin [3]; however, conclusions on efficacy are complicated by study methodologic flaws and conflicting data [10]. In addition, antiperspirant use is associated with high risk for skin irritation.
SUMMARY AND RECOMMENDATIONS 總結.
● 摩擦的水泡是常見問題, 在手腳最容易發生. The friction blister is a common disorder that occurs when frictional forces repeatedly applied to the skin lead to separation within the epidermis. Friction blisters are most likely to occur on the hands and feet.
●摩擦的水泡通常會形成線狀或橢圓的水泡. 內含清澈液體. 也可能出血. 常會造成疼痛. Friction blisters generally present as vesicles or bullae in linear or oval configurations. The blister cavity typically contains clear fluid. Hemorrhagic vesicles or bullae may also occur. Discomfort is common.
●摩擦的水泡通常會自然痊癒. 治療在於減輕症狀, 減少感染率. Friction blisters can heal spontaneously provided the causative frictional force is removed. Treatment is focused on reducing symptoms and minimizing risk for secondary infection.
●造成疼痛或限制活動的水泡在引流之後通常症狀會緩解, 引流技巧要注意維持水泡頂部完整. 有助於降低引流後的感染率. 破裂的水泡應每天清潔, 使用乾淨乾燥的敷料覆蓋. Patients with painful blisters or blisters that cause functional limitations often have improvement in symptoms with blister drainage. A drainage technique that leaves the blister roof may help to reduce risk for secondary infection after drainage. Ruptured blister sites should be cleansed daily and covered with a clean, dry dressing.
●無症狀的水泡讓它維持原狀. 會自然吸收. Asymptomatic blisters can be left intact and allowed to resolve spontaneously.
●預防方式在於減少局部摩擦. 要找出引起水泡的原因. 針對性的預防. Measures to reduce blister recurrence are aimed at reducing frictional forces on the skin. Factors contributing to blister formation should be reviewed, including the inciting activity, potential exacerbating factors (eg, moisture, sweating, heat), and the objects that were in contact with the skin.
from 2014 野外醫學期刊 基本傷口處置. 摩擦造成的水泡.
September 2014Volume 25, Issue 3, Pages 295–310 Friction Blisters
一篇回顧性研究說. 在阿帕拉契山脈健行的人有 64% 受到水泡困擾.
Blisters are ubiquitous and disproportionately disabling wounds in the austere environment. A review of the medical risks of hiking the Appalachian Trail reported that foot blisters affected 64% of all hikers.111 During a 12-month period of Operation Iraqi Freedom 1, the incidence of foot blisters was 33%.
對於水泡的處置. 預防勝於治療. 穿一雙或兩雙襪子. 可排除水氣. 預防水泡. 另一篇研究說. 穿薄的PE襪可減少水泡的數量和嚴重度. 關於 moleskin, duoderm, adhesive tape, emollients, tincture of benzoin, or foot powders 是否能預防水泡則缺乏足夠研究資料. 一篇雙盲研究發現. 鋁基底的止汗劑塗抹在足底連續三天可減少 27% 水泡.
Blisters are a prominent example of the adage that “an ounce of prevention is worth a pound of cure.” Single or double socks capable of wicking away moisture appear to be beneficial in preventing blisters.113, 114 One study showed a marked reduction in blisters in runners with the use of acrylic vs cotton socks.115 Another study showed a reduction in the number and severity of blisters with a thin polyester undersock.116 Little evidence exists to support a preventive role for moleskin, duoderm, adhesive tape, emollients, tincture of benzoin, or foot powders. In a double-blind, placebo-controlled study, aluminum-based antiperspirant (20% aluminum chloride hexahydrate solution without emollients or perfumes) applied to the soles of the feet for at least 3 consecutive days reduced blisters by 27% vs placebo.117
小水泡與熱點應加以保護, 減少局部壓力, 例如用甜甜圈形狀的墊片. 或使用含有凝膠的貼布. 大一點的水泡(超過 5mm) 考慮引流. 但不要移除. 引流之後使用含凝膠的貼片或抗生素藥膏加上紗布覆蓋.
Small blisters (<5 mm in diameter) and hot spots should be protected with pressure relief, such as a donut-shaped pad (eg, moleskin), or covered with hydrogel or hydrocolloidal dressings. Blisters larger than 5 mm in diameter should be drained, but not unroofed, then covered with a hydrocolloid or hydrogel patch or equivalent (petrolatum or antibacterial ointment covered with gauze or moleskin).
使用組織膠的研究較少. 一篇研究評估 2-octyl cyanoacrylate (DERMABOND 成分) 的效用. 發現相較於標準處置. 較不方便. 且無治療效益.
Little evidence exists to support the use of tissue adhesives for blister treatment. One study prospectively evaluated the use of 2-octyl cyanoacrylate compared with standard treatment and found a greater degree of procedural discomfort but no treatment advantage with the 2-octyl cyanoacrylate.119
Recommendation~ 建議. 正確使用鞋子, 提供乾燥環境, 使用排汗襪. 能避免水泡產生. Blister prevention is facilitated by the use of proper footwear and promoting a dry environment for the foot, including the use of a wicking sock system. Recommendation grade: 1C.
Recommendation~ 建議, 小水泡及熱點應加以保護, 減少局部壓力, 例如使用甜甜圈形狀墊片, 或使用含凝膠敷料. Small blisters (<5 mm in diameter) and hot spots should be protected with pressure relief, such as a donut-shaped pad (eg, moleskin), or covered with hydrogel or hydrocolloidal dressings. Recommendation grade: 1C.
Recommendation~ 建議, 水泡超過 5mm 考慮引流, 不要整個弄破, 再以含凝膠的敷料覆蓋, 或以凡士林敷料, 抗生素加上紗布覆蓋. Blisters larger than 5 mm in diameter should be drained, but not unroofed, then covered with a hydrocolloid or hydrogel patch or equivalent (petrolatum or antibacterial ointment covered with gauze or moleskin). Recommendation grade: 1C.
第三個參考資料是一本教科書. MINOR EMERGENCY. 第三版. 第168章. 電子版 PAGE 684. (紙面PAGE674)上面的建議與其他資料並不完全一致.
Presentation 預防. 穿新鞋或不合腳的鞋. 或走的比平常遠. 足部後跟與足底可能出現水泡. 這些水泡也可能出血. 病患會因次發性感染, 疼痛性化膿, 蜂窩性組織炎或淋巴炎就醫
After wearing a pair of new or ill-fitting shoes or having gone on an unusually long hike or run, the patient complains of an uncomfortable open or intact blister on the posterior heel or ball of the foot. Occasionally, these blisters will be hemorrhagic. Secondary infection may be the cause of the visit, after painful pustules, cellulitis, or lymphangitis develops.
What To Do: 該做哪些呢?
對於已經破裂的水泡, 或水泡出現感染. 移除上面的皮, 使用無毒的清潔劑將患處清潔乾淨 (1% 優碘溶液). 將傷口用抗生素藥膏覆蓋. 不建議使用 NEOMYCIN (作者也太焦慮了吧). 貼上膠布. 衛教病患持續清洗患處. 蓋上敷料, 直到患處痊癒. 通常需五天.
For torn or open blisters or blisters that have become infected, remove the overlying cornified epithelium with fine scissors and forceps. Clean the area thoroughly with a nontoxic skin cleanser (e.g., 1% povidone-iodine solution). Cover the wound with antibiotic ointment that does not contain neomycin and with a simple strip bandage. Have the patient wash the area and repeat the dressings until complete healing has taken place. It usually takes about 5 days for a new stratum corneum to form.
如果出現蜂窩性組織炎或淋巴炎. 給予抗生素.
When cellulitis or lymphangitis is present, provide appropriate antibiotics (see Chapter 166).
對於 1 公分以下小水泡. 或尚未破裂的水泡. 讓皮膚保持完整. 使用保護性敷料覆蓋.
For small (less than 1 cm) untorn or closed blisters that are not infected, the skin may be left intact and covered with a protective dressing.
對於 1 公分以上的水泡可考慮減壓(引流). 使用優碘消毒之後, 用 25G 針頭抽吸. 直到水泡抽乾.
To provide comfort for lesions larger than 1 cm, the blister can be decompressed. Cleanse the area with povidone-iodine; then, using a 25-gauge needle, aspirate the blister fluid until the blister has completely collapsed.
可局部塗抹抗生素藥膏. 再貼上醫療膠布. 或使用透明貼布覆蓋穿刺部位. 或使用含凝膠的敷料. 或使用組織膠覆蓋穿刺部位. 還有其他各種不同商品. 最後可以再加上一個襯墊. 提供保護及舒適度. To prevent contamination and infection, either provide continuous antibacterial ointment (bacitracin) and strip bandage protection, or cover the punctured blister with a polyurethane film (such as OpSite) or a hydrogel dressing (such as Spenco 2nd Skin or Vigilon), or seal the needle puncture with cyanoacrylate (Dermabond). Other acceptable protective coverings include the hydrocolloid, Duoderm; the occlusive dressing, moleskin; or the over-the-counter (OTC) liquid bandage, New-Skin. Additional padding may also be protective and comforting.
教導病患如何避免水泡產生. 穿合腳的鞋子. 鞋子穿久了要汰換. 走路和跑步需逐漸加量. 好的襪子能吸濕. 鞋墊也可以預防水泡. 穿兩種材質不同的襪子能減少皮膚摩擦. 預防水泡. 美國陸軍學院學員, 在進行 21 公里行軍時, 使用 20% 氯化鋁的止汗劑連續使用三天, 可降低 50% 足底水泡的生成. 但使用止汗劑可能造成皮膚刺激.
Instruct the patient about friction blister prevention. A properly fitting shoe is essential, and even comfortable shoes need to be broken in gradually. Walking and running activities should be slowly increased day by day. Good socks with moisture wicking and padded insoles can also help prevent friction blisters. Wearing two pairs of socks that are made of different materials may reduce skin friction and prevent blisters. United States Military Academy cadets who applied an antiperspirant solution containing 20% aluminum chloride to their feet for at least 3 consecutive days reduced their risk for developing foot blisters during a 21-km hike by approximately half. The use of such antiperspirants 止汗劑 unfortunately causes a high incidence of skin irritation.
不要做的事情: 避免使用含新黴素的藥膏. 以免過免. 不要將水泡戳破. 裸露的皮膚可能會疼痛及增加感染率.
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