Blood Blisters: Do's and Dont's

You can't help but cringe when you see one.

And you certainly don't want these to be yours!

It pays to have a healthy respect for blood blisters as they pose a heightened risk for infection. Particularly for trail runners and during multiday races. 

But do you know what makes a blood blister? 

And how do you deal with them? Do you pop them or not?

 
Blood blisters under big toes (image credit)

Blood blisters under big toes (image credit)

 

Where does the blood come from?

As the name suggests, there's blood in a blood blister. That's what causes the red, purple, black discolouration. But if you remember from the anatomy of the skin, there are no blood vessels in the epidermis (where friction blisters form). Blood vessels are located in the dermis - that's the skin layer below the epidermis. So how does the blood get there?

It's an indication there's been deeper injury with a significant pressure component. That's why blood blisters often occur over joints and bony prominences: like the back of the heel, the toes and the metatarsal heads (ball of the foot). Excess pressure ruptures capillaries and this bleeding tracks into the blister. 

 
Blood vessels exist in the dermis - not the epidermis where blisters form

Blood vessels exist in the dermis - not the epidermis where blisters form

 

They are still an injury of shear, with friction being a major factor. But when high friction combines with excessive localised pressure, a blood blister is the result.

How long do they last?

When you have a blood blister, blood from the dermis stains the cells it comes into contact with. We know it takes somewhere from 30 to 48 days for full epidermal cell turnover - that is for cells to travel from their deepest to most superfical, to be shed as dead skin cells. So it could take that long before all trace disappears. The blood will dry relatively quickly, assuming you take away the cause. If you don't deal with the cause, your blood blister will last longer. And as the blood dries, it becomes a very dark (almost black) colour.

Cause and Prevention

Structural causes of blood blisters

Bony prominences are at most risk, like a bunion for example. Having a bunion makes the forefoot wider. It's not necessarily the bunion itself at most risk of developing a blood blister. The weightbearing undersurface is - as the prominent joint bulges over the sole of the shoe. This provides a concentration of pressure. Coupled with high friction, there's a blood blister waiting to happen.

Blood blister under a callus (image credit)

Blood blister under a callus (image credit)

Toe blood blister (image credit)

Toe blood blister (image credit)

Biomechanical causes of blood blisters

The blood blisters under the big toes in the first image of this article are a consequence of the foot's biomechanics. There's an important function of the 1st MPJ (big toe knuckle) called the windlass mechanism. When it's not working adequately, there can be extremely high pressure under the joint of the big toe - where these blisters are.

Functional hallux limitus (inefficient windlass mechanism) as a cause of blood blisters under the big toe.

Functional hallux limitus (inefficient windlass mechanism) as a cause of blood blisters under the big toe.

The best way to deal with this is with to see a Podiatrist because they know how to facilitate the windlass mechanism - treatment will likely include orthotics and calf stretches and maybe some other things. You'll get a little more more insight into this kind of thing in Chapter 5 of our premium blister resource "The Advanced Guide to Blister Prevention".

Treatment

If you miss the blister prevention boat and end up with a blood blister, do all the normal things for blister treatment. But now, preventing infection really is your priority! Consider the options below, depending on your blister location, the environment you're in and what gear you have access to. 

1) Take away all pressure

If it's possible, remove all pressure to ensure the blister roof remains intact and allow it to heal in its own time. For the blood blister on top of your toe, simply wearing open-toed sandals might work. Or open-backed scuffs for heel blisters. Barefeet or complete nonweightbearing may be your only option, depending where your blood blister is. By taking away all pressure, the blister remains intact with no chance of infection.

But if your blood blister is on the weightbearing area of the foot, or you have to wear shoes, it's not quite so simple. 

2) Reduce some pressure and cut friction levels

There are parts of your foot where taking away all pressure might not be possible - like under the ball of the foot. And there are times when you just have to keep going. This is where pressure deflection can help in conjunction with reducing friction levels. Thick adhesive orthopedic felt can be cut into "donut pads" with the blister positioned in the cavity to take pressure off it. And before you do anything else, read this about reducing friction to treat blisters.

I would use much thicker felt than that pictured below.

 
This is a donut pad - it's very thin though. to provide more pressure deflection, use a thicker felt/moleskin material (image credit).

This is a donut pad - it's very thin though. to provide more pressure deflection, use a thicker felt/moleskin material (image credit).

 

Popping Your Blood Blister

There are times when keeping the blister roof intact is not the best option. It can be better to take matters into your own hands rather than ignore it and simply hope for the best. If you have the right equipment, you could deal with this appropriately and safely. It sure beats putting your blood blister with roof intact back into your shoe with no dressing and no pressure relief and just leaving it to chance. 

If the amount of blood accumulating is causing pain; if the blister is too big and likely to tear; if you have to carry on running or hiking; it may be best to lance it. I would probably lance that blood blister on the top of the 4th toe pictured above. But you must realise the increased risk of infection. Remember, it is OK to not lance your blood blister. If in doubt, don't pop it! Read this article to help you decide if to lance or leave alone

If you are going to lance your blister, you need to do it in a clean environment using clean techniques. To do this, you'll need certain equipment.

  1. Clean your hands and foot (soap and water or antibacterial hand gel)
  2. Lance with a sterile implement (sterile scalpel blade or needle)
  3. Apply antiseptic (betadine) and dress with a sterile dressing
  4. Remove or deflect pressure
  5. If you want your blister to heal as quickly as possible, you've also got to cut friction levels.
  6. Then you need to keep it clean and monitor over the coming days for signs of infection. If you suspect there is infection, seek medical help.

Please realise the risk of bacterial infection. For the following few days, you'll need to be on the watch for signs of infection which include redness, swelling, pain and pus. And if you notice red streaks extending from your blister up your leg, this is serious and you need urgent medical attention. 

In conclusion

Do

  1. Get the pressure off (or down)
  2. Speed healing by reducing friction!
  3. Be clean, use antiseptic and a sterile non-adherent dressings to protect from infection

Don't

  1. Don't just ignore it and keep going or it will tear and be open to infection
  2. Don't ignore the benefits of lancing it (but only if the situation is right!) 
  3. Don't neglect pressure relief and friction relief

The Next Step

This is what you need to deal with your blood blister the best way possible.

 
Advanced Blister Kit
69.00

A blister kit that features the products and materials used by professionals for advanced blister management capabilites - the kind of stuff you don't find in basic kits. Packs down to a tiny 10cm x 15cm x 1cm and only 64 grams. Hikers and ultrarunners have asked for this.

  1. Keep your blister as pain-free as possible
  2. Stop your blister roof from tearing
  3. Prevent your blister from getting infected
  4. Allow your blister heal as quickly as possible
  5. And stop your hotspot from becoming a blister in the first place

CONTENTS

  • 2 x sterile Comfeel dressings (6cm x 4cm)
  • 1 x adhesive felt sheet (9cm x 11cm)
  • 2 x sterile Scalpel blades (size 15)
  • 2 x ENGO large ovals
  • 1 x Silicone gel toe sleeve (small)
  • 1 x Silicone gel toe sleeve (large)
  • 2 x Povidone iodine (Betadine) swabs
  • 2 x Gloves (medium)
  • ½ metre Fixomull tape (5cm)
  • 2 x sterile Cutiplast / Primapore dressings (7cm x 5cm)
  • 2 x Skin Prep swabs
  • Instructions included
Quantity:
Add To Cart
 

Watch the video explaining how to use each of these contents.


Rebecca Rushton

Written by Rebecca Rushton

Rebecca is an Australian podiatrist with over 20 years experience. She has spent a lifetime dealing with her own blister prone feet in her sporting and everyday life. Rebecca specialises in helping athletes and sports medicine professionals figure out how to manage foot blisters with ease. And for kicks, she enjoys providing blister care at multiday ultramarathon events.

Rebecca is the founder of Blister Prevention and author of both "The Blister Prone Athlete's Guide To Preventing Foot Blisters" and "The Advanced Guide to Blister Prevention".