MSB Review
SULZBERGER O N FRICTION BLISTERING WILLIAM A, AKERS, M.D,, COL,, MC
Friction blisters are a common injury experienced by almost everyone. From 1964 to 1970, Marion B. Sulzberger, M.D., mounted a scientific assault against this plebian disease. He devised a logical, step-by-step approach toward understanding the blister, and he recruited over a period of time different young investigators as collaborators. Before he began his studies, Naylor'--^ had published the only scientific studies on friction blistering. Sulzberger confirmed Naylor's findings and greatly expanded knowledge of the friction blister and its formation. His findings are as true today as when they were published. For the military, the ravages of friction blisters cost several million dollars a year in wages, hospitalization, and training costs. One recruit out of every 100 is hospitalized for the complications of infection and cellulitis resulting from foot blisters. Because of severe blisters of the feet, 1 recruit out of every 10 loses at least 3 days of training which must be made up. The performance of professional and amateur athletes frequently is limited by blisters.
From the Department of Dermatology Research, Letterman Army Institute of Research, San Francisco, California
forces being transmitted downward into the epidermis. If it is not sufficiently resistant, an abrasion will result.'' The skin must be relatively immobile and held down by underlying structures. Friction blisters can be produced readily on the palms and soles, but only with difficilty can they be produced on "thin" or "loose" skin. Experimentally, about half of the time, blisters can be rubbed on the body surface by splinting or immobilizing the skin and rubbing gently to avoid an abrasion. Experimental friction blisters have been rubbed on the palms and soles of Macaque monkeys.^ Stages Friction blistering occurs in 2 stages: 1. A cleft appears always in the middle to upper malpighian layer. This location is remarkably consistent. The blister roof is composed of the stratum corneum, the stratum granulosum, and both normal and damaged prickle cells. The base consists variably of normal-appearing basal and prijkle cells.'' Focal areas may appear coagulated, while in other areas of the base, the cytoplasm of the cells lose their homogeneity and become intensely eosinophilic. Some cells demonstrate vacuolization and nuclear pyknosis. Many
Blistering
To produce a friction blister, the stratum corneum must be sufficiently thick and resistant to withstand the frictional Address for reprints to: Librarian, Letterman Army Institute of Research, Presidio of San Francisco, CA 94219.
369
370
INTERNATIONAL JOURNAL OF DERMATOLOCY
cells are elongafed as though they were mechanically stretched. The dermis shows little effect. The blood vessels may be slightly dilated and congested. Dermal sweat ducts are preserved.' AutoradJographic studies confirm the selective damage to the stratum malpighii.'^ Unlike most injuries to the epidermis, the friction blister results in rapid cell death, no migration of formed blood elements, and essentially no progressive damage. 2. Fluid pours into the intraepidermal cleft under hemodynamic pressure.' A blister rubbed on the palm will not fill if the hand is elevated over the head, where the mean arterial blood pressure at the wrist is 40 mm Hg and the effective venous pressure is zero. In the dependent position, the mean arterial pressure at the wrist is about 125 mm Hg and the effective venous pressure is about 35 mm Hg. The communication between blood vessels and blisters cavity is not direct since the blister takes 1 to 2 hours to fill. Friction blister fluid qualitatively reflects the composition of serum, both normal and abnormal. The fluid appears to be either a selective transudate or the result of some type of active transport. The sodium, potassium, and chloride concentrations are not significantly different from those of serum but the calcium values are at least 20% lower.'" At 2 hours after the blister has been produced, the albumin and the immunoglobulins IgC and IgM values are onetenth those of plasma, while fibrinogen and fibrinolysin are absent.^' The alphai globulin Is significantly elevated while the beta globulin Is the same as the serum values. Syphilitic reagin, the abnormal gamma globulin of multiple myeloma, and the radioactivity of intravenously administered radioordinated C'M) human serum albumin are detectable in the blister fluid.'o
June 1977
Vol. 16
Variables
The time needed to produce a blister varies from person to person and from skin site to skin site for an individual. Moving only one centimeter on the palm or heel results in a different coefficient of friction for the skin. Moisture of the skin is one known variable influencing the time required for blistering. Dry skin surfaces and wet, flooded skin surfaces produce less friction than barely moist skin when rubbed with the same material.'• '2 Moist skin is most susceptible to friction blistering. Temperature is another known variable. Friction blisters are not thermal burns — not second degree burns. We inserted intradermally thermistors in the palms of 4 volunteers and rubbed over the thermistor tips. The temperature did not rise more than 3.5 C either immediately beneath the tissue being rubbed or in the material rubbing the tissue.*' Heating monkey palms to register 53 C on the intradermal thermistors could not raise a thermal blister no matter how long the heat was applied.''* Histologically, friction blisters do not resemble burns. Clinical observation suggests that friction blisters occur more readily in warm than in cold environments. Work with volunteers in environmental chambers reveals that foot blisters rarely occur in an arctic chamber but commonly occur in a tropical chamber. Friction blisters were rubbed on monkey palms and soles at chilled (14 C), normal (30 C), and warm (46 C) skin temperatures. It took a longer time for friction blister formation on chilled sites and shorter time on warm skin than on normal skin temperature sites. The time required for blistering varies inversely with the initial skin temperature.''' Production of friction blisters for study on a subject can be done simply by tak-
No. 5
FRICTION BLISTERING
ing an ordinary pencil and pressing the eraser against the skin surface to be rubbed and the operator briskly rotating the pencil to-and-fro between his palms. Measurement of forces involved in blistering requires elaborate machines and recorders.'' '• '^^ '-^ So far, no machine is perfect. Much work has been put into perfecting the instruments to remove variables because the investigator faces the large, uncontrollable site-to-site variation on the human skin.
Akers
371
The natural blister top is the best dressing, provided it remains intact. If it is torn, one should remove the top, apply topical antibiotic ointment, and bandage. Bandages tend to become loose rapidly on the feet and to get wet on the hands. In the search for a tenacious bandage, isoamyl cyanoacrylate, a liquid plastic, is being evaluated experimentally as a dressing for raw blister bases.'^ Pain is lessened, walking is comfortable, and infection has not been a problem in small clinical trials.
Treatment An effort was made to determine the best way to treat experimentally produced friction blisters. Blisters were rubbed on 83 adult volunteers' palms and heels."^ Healing was observed for 3 weeks with and without blister fluid drainage and with and without blister top removal. Both natural fluid resorption and aspiration with a 26-gauge needle resulted in the adherence of some of the blister tops to their bases. The best results were obtained by aspirating at 2, 6, and 12 hours with 92% adherence at 96 hours after injury. A single aspiration between 24 to 36 hours resulted in adherence of the top to the base in 85% of volunteers at 96 hours. Adherent tops were much more comfortable than denuded blisters. In undrained blisters, only 16% had adherence at 48 hours. This percentage rose to 52% by 96 hours for those few blisters which remained unbroken. Most undrained blister tops ruptured, thereby exposing the bases. Deroofed blisters on the heels were the most painful. With these, halos of inflammation and short, single streaks of ascending lymphagitis developed. The preferable method is to preserve the blister top and drain the fluid 3 times during the first 24 hours or once at 24 hours.
Prevention A satisfactory method of prophylaxis against blisters still eludes us. Certainly, well-fitted footgear lessens the problem. In some of our experiments, the metal rubbing head of the blister machine was covered with various materials, such as rough or smooth shoe-lining leather, plastics, or rubber.'^ Over the material were fastened patches from different types of government-issue socks. The friction produced was more a function of the backing material than the sock material which actually rubbed the skin. This finding suggests a method of avoiding blisters: making a 3-layer sock with the outer layers gripping the skin and shoelining while the inner layer dissipates the frictional forces. A material as slippery as Teflon for the heel counter and toecap lining could be helpful in reducing blistering. Various preparations to reduce the skin's coefficient of friction by producing slipperiness or reducing sweating can be tested. Conclusion This brief review summarizes Sulzberger's contributions on friction blistering. A few references do not bear his name but they resulted from supporting
372
INTERNATIONAL JOURNAL OF DERMATOLOCY
Studies done while he was actively directing the program. Friction blisters are not thermal burns, but are caused by shearing forces within the epidermis. These produce a cleft in the middle to upper stratum malpighii into which fluid passes, provided a sufficient arterial pressure gradient exists. Friction blister fluid contains most of the proteins of the serum, except fibrinogen, but in lesser quantities. Electrolytes are present in the same quantities as the serum except the calcium is lower. Drainage of intact blisters at 24 to 36 hours leads to a firm reattachment of the top and forms a serviceable dressing. Friction blisters can be produced on monkey paws as well as humans. Instruments and information now available permit comparison of the friction producing properties of different fabrics, materials, foot wear, and topical applications. References 1. Naylor, P. E. D.: The measurement of epidermal strength. Trans. St. John's Hosp. Dermatol. Soc. 31:29, 1952. 2. Naylor, P. E. D.: The skin surface and friction. Br. |. Dermatol. 67:239, 1955. 3. Naylor, P. E. D.: Experimental friction blisters. Br. J. Dermatol. 67:327, 1955. 4. Cortese, T. A., Jr., Criffin, T. B., and Sulzberger, M. B.: Friction blisters under controlled conditions. In XIII, Congressus Internationalis Dermatologiea — Munchen 1967. Berlin, Springer-Verlag, 1968, pp. 1273-1275.
June 1977
Vol. 16
5. Cortese, T. A., Jr., Criffin, T. B., Layton, L. L., and Hutsell, T. C : Experimental friction blisters in Macaque monkeys. 1. Invest. Dermatol. 53:172, 1969. 6. Cortese, T. A., Jr., Eukuyama, K., Epstein, W., and Sulzberger, M. B.: Treatment of friction blisters. Arch. Dermatol. 97:717, 1968. 7. Sulzberger, M. B., and Cortese, T. A., Jr.: Observation on the blister base. Br. J. Clin. Pract. 22:249, 1968. 8. Epstein, W. L., Fukuyama, K., and Cortese, T. A., Jr.: Autoradiographic study of friction blisters. RNA, DNA, and protein synthesis. Arch. Dermatol. 99:94, 1969. 9. Sulzberger, M. B., Cortese, T. A., |r., Fishman, L., and Wiley, H. S.: Studies on blisters produced by friction. 1. Results of linear and twisting technics. ). Invest. Dermatol. 47:456, 1966. 10. Cortese, T. A., |r., Sams, W. M., and Sulzberger, M. B.: Studies on blisters produced by friction. 11. The blister fluid. J. Invest. Dermatol. 50:47, 1968. 11. Schmid, P.: Quantitation of specific proteins in blister fluid. |. Invest. Dermatol. 55:244, 1970. 12. Sulzberger, M. B., Cortese, T. A., |r., Sams, W. M., and Wiley, H. S.: Studies on experimental friction blisters. In Sven FHellerstrom 65 years. Acta. Derm. Venereol. (Special Issue) 154, 1966. 13. Akers, W. A., and Sulzberger, M. B.: The friction blister. Milit. Med. 137:1, 1972. 14. Criffin, T. B., Cortese, T. A., Jr., Layton, L. L., and Sulzberger, M. B.: Inverse time and temperature relationship in experimental friction blisters Abstract. Society of Investigative Dermatology, Atlantic City, N), May 3, 1969. 15. Akers, W. A., Leonard, F., Ousterhout, D. K., and Cortese, T. A., Jr.: Treating friction blisters with alkyl-a-cyanoacrylates. Arch. Dermatol. 107:544, 1973. .
SULZBERGER O N FRICTION BLISTERING WILLIAM A, AKERS, M.D,, COL,, MC
Friction blisters are a common injury experienced by almost everyone. From 1964 to 1970, Marion B. Sulzberger, M.D., mounted a scientific assault against this plebian disease. He devised a logical, step-by-step approach toward understanding the blister, and he recruited over a period of time different young investigators as collaborators. Before he began his studies, Naylor'--^ had published the only scientific studies on friction blistering. Sulzberger confirmed Naylor's findings and greatly expanded knowledge of the friction blister and its formation. His findings are as true today as when they were published. For the military, the ravages of friction blisters cost several million dollars a year in wages, hospitalization, and training costs. One recruit out of every 100 is hospitalized for the complications of infection and cellulitis resulting from foot blisters. Because of severe blisters of the feet, 1 recruit out of every 10 loses at least 3 days of training which must be made up. The performance of professional and amateur athletes frequently is limited by blisters.
From the Department of Dermatology Research, Letterman Army Institute of Research, San Francisco, California
forces being transmitted downward into the epidermis. If it is not sufficiently resistant, an abrasion will result.'' The skin must be relatively immobile and held down by underlying structures. Friction blisters can be produced readily on the palms and soles, but only with difficilty can they be produced on "thin" or "loose" skin. Experimentally, about half of the time, blisters can be rubbed on the body surface by splinting or immobilizing the skin and rubbing gently to avoid an abrasion. Experimental friction blisters have been rubbed on the palms and soles of Macaque monkeys.^ Stages Friction blistering occurs in 2 stages: 1. A cleft appears always in the middle to upper malpighian layer. This location is remarkably consistent. The blister roof is composed of the stratum corneum, the stratum granulosum, and both normal and damaged prickle cells. The base consists variably of normal-appearing basal and prijkle cells.'' Focal areas may appear coagulated, while in other areas of the base, the cytoplasm of the cells lose their homogeneity and become intensely eosinophilic. Some cells demonstrate vacuolization and nuclear pyknosis. Many
Blistering
To produce a friction blister, the stratum corneum must be sufficiently thick and resistant to withstand the frictional Address for reprints to: Librarian, Letterman Army Institute of Research, Presidio of San Francisco, CA 94219.
369
370
INTERNATIONAL JOURNAL OF DERMATOLOCY
cells are elongafed as though they were mechanically stretched. The dermis shows little effect. The blood vessels may be slightly dilated and congested. Dermal sweat ducts are preserved.' AutoradJographic studies confirm the selective damage to the stratum malpighii.'^ Unlike most injuries to the epidermis, the friction blister results in rapid cell death, no migration of formed blood elements, and essentially no progressive damage. 2. Fluid pours into the intraepidermal cleft under hemodynamic pressure.' A blister rubbed on the palm will not fill if the hand is elevated over the head, where the mean arterial blood pressure at the wrist is 40 mm Hg and the effective venous pressure is zero. In the dependent position, the mean arterial pressure at the wrist is about 125 mm Hg and the effective venous pressure is about 35 mm Hg. The communication between blood vessels and blisters cavity is not direct since the blister takes 1 to 2 hours to fill. Friction blister fluid qualitatively reflects the composition of serum, both normal and abnormal. The fluid appears to be either a selective transudate or the result of some type of active transport. The sodium, potassium, and chloride concentrations are not significantly different from those of serum but the calcium values are at least 20% lower.'" At 2 hours after the blister has been produced, the albumin and the immunoglobulins IgC and IgM values are onetenth those of plasma, while fibrinogen and fibrinolysin are absent.^' The alphai globulin Is significantly elevated while the beta globulin Is the same as the serum values. Syphilitic reagin, the abnormal gamma globulin of multiple myeloma, and the radioactivity of intravenously administered radioordinated C'M) human serum albumin are detectable in the blister fluid.'o
June 1977
Vol. 16
Variables
The time needed to produce a blister varies from person to person and from skin site to skin site for an individual. Moving only one centimeter on the palm or heel results in a different coefficient of friction for the skin. Moisture of the skin is one known variable influencing the time required for blistering. Dry skin surfaces and wet, flooded skin surfaces produce less friction than barely moist skin when rubbed with the same material.'• '2 Moist skin is most susceptible to friction blistering. Temperature is another known variable. Friction blisters are not thermal burns — not second degree burns. We inserted intradermally thermistors in the palms of 4 volunteers and rubbed over the thermistor tips. The temperature did not rise more than 3.5 C either immediately beneath the tissue being rubbed or in the material rubbing the tissue.*' Heating monkey palms to register 53 C on the intradermal thermistors could not raise a thermal blister no matter how long the heat was applied.''* Histologically, friction blisters do not resemble burns. Clinical observation suggests that friction blisters occur more readily in warm than in cold environments. Work with volunteers in environmental chambers reveals that foot blisters rarely occur in an arctic chamber but commonly occur in a tropical chamber. Friction blisters were rubbed on monkey palms and soles at chilled (14 C), normal (30 C), and warm (46 C) skin temperatures. It took a longer time for friction blister formation on chilled sites and shorter time on warm skin than on normal skin temperature sites. The time required for blistering varies inversely with the initial skin temperature.''' Production of friction blisters for study on a subject can be done simply by tak-
No. 5
FRICTION BLISTERING
ing an ordinary pencil and pressing the eraser against the skin surface to be rubbed and the operator briskly rotating the pencil to-and-fro between his palms. Measurement of forces involved in blistering requires elaborate machines and recorders.'' '• '^^ '-^ So far, no machine is perfect. Much work has been put into perfecting the instruments to remove variables because the investigator faces the large, uncontrollable site-to-site variation on the human skin.
Akers
371
The natural blister top is the best dressing, provided it remains intact. If it is torn, one should remove the top, apply topical antibiotic ointment, and bandage. Bandages tend to become loose rapidly on the feet and to get wet on the hands. In the search for a tenacious bandage, isoamyl cyanoacrylate, a liquid plastic, is being evaluated experimentally as a dressing for raw blister bases.'^ Pain is lessened, walking is comfortable, and infection has not been a problem in small clinical trials.
Treatment An effort was made to determine the best way to treat experimentally produced friction blisters. Blisters were rubbed on 83 adult volunteers' palms and heels."^ Healing was observed for 3 weeks with and without blister fluid drainage and with and without blister top removal. Both natural fluid resorption and aspiration with a 26-gauge needle resulted in the adherence of some of the blister tops to their bases. The best results were obtained by aspirating at 2, 6, and 12 hours with 92% adherence at 96 hours after injury. A single aspiration between 24 to 36 hours resulted in adherence of the top to the base in 85% of volunteers at 96 hours. Adherent tops were much more comfortable than denuded blisters. In undrained blisters, only 16% had adherence at 48 hours. This percentage rose to 52% by 96 hours for those few blisters which remained unbroken. Most undrained blister tops ruptured, thereby exposing the bases. Deroofed blisters on the heels were the most painful. With these, halos of inflammation and short, single streaks of ascending lymphagitis developed. The preferable method is to preserve the blister top and drain the fluid 3 times during the first 24 hours or once at 24 hours.
Prevention A satisfactory method of prophylaxis against blisters still eludes us. Certainly, well-fitted footgear lessens the problem. In some of our experiments, the metal rubbing head of the blister machine was covered with various materials, such as rough or smooth shoe-lining leather, plastics, or rubber.'^ Over the material were fastened patches from different types of government-issue socks. The friction produced was more a function of the backing material than the sock material which actually rubbed the skin. This finding suggests a method of avoiding blisters: making a 3-layer sock with the outer layers gripping the skin and shoelining while the inner layer dissipates the frictional forces. A material as slippery as Teflon for the heel counter and toecap lining could be helpful in reducing blistering. Various preparations to reduce the skin's coefficient of friction by producing slipperiness or reducing sweating can be tested. Conclusion This brief review summarizes Sulzberger's contributions on friction blistering. A few references do not bear his name but they resulted from supporting
372
INTERNATIONAL JOURNAL OF DERMATOLOCY
Studies done while he was actively directing the program. Friction blisters are not thermal burns, but are caused by shearing forces within the epidermis. These produce a cleft in the middle to upper stratum malpighii into which fluid passes, provided a sufficient arterial pressure gradient exists. Friction blister fluid contains most of the proteins of the serum, except fibrinogen, but in lesser quantities. Electrolytes are present in the same quantities as the serum except the calcium is lower. Drainage of intact blisters at 24 to 36 hours leads to a firm reattachment of the top and forms a serviceable dressing. Friction blisters can be produced on monkey paws as well as humans. Instruments and information now available permit comparison of the friction producing properties of different fabrics, materials, foot wear, and topical applications. References 1. Naylor, P. E. D.: The measurement of epidermal strength. Trans. St. John's Hosp. Dermatol. Soc. 31:29, 1952. 2. Naylor, P. E. D.: The skin surface and friction. Br. |. Dermatol. 67:239, 1955. 3. Naylor, P. E. D.: Experimental friction blisters. Br. J. Dermatol. 67:327, 1955. 4. Cortese, T. A., Jr., Criffin, T. B., and Sulzberger, M. B.: Friction blisters under controlled conditions. In XIII, Congressus Internationalis Dermatologiea — Munchen 1967. Berlin, Springer-Verlag, 1968, pp. 1273-1275.
June 1977
Vol. 16
5. Cortese, T. A., Jr., Criffin, T. B., Layton, L. L., and Hutsell, T. C : Experimental friction blisters in Macaque monkeys. 1. Invest. Dermatol. 53:172, 1969. 6. Cortese, T. A., Jr., Eukuyama, K., Epstein, W., and Sulzberger, M. B.: Treatment of friction blisters. Arch. Dermatol. 97:717, 1968. 7. Sulzberger, M. B., and Cortese, T. A., Jr.: Observation on the blister base. Br. J. Clin. Pract. 22:249, 1968. 8. Epstein, W. L., Fukuyama, K., and Cortese, T. A., Jr.: Autoradiographic study of friction blisters. RNA, DNA, and protein synthesis. Arch. Dermatol. 99:94, 1969. 9. Sulzberger, M. B., Cortese, T. A., |r., Fishman, L., and Wiley, H. S.: Studies on blisters produced by friction. 1. Results of linear and twisting technics. ). Invest. Dermatol. 47:456, 1966. 10. Cortese, T. A., |r., Sams, W. M., and Sulzberger, M. B.: Studies on blisters produced by friction. 11. The blister fluid. J. Invest. Dermatol. 50:47, 1968. 11. Schmid, P.: Quantitation of specific proteins in blister fluid. |. Invest. Dermatol. 55:244, 1970. 12. Sulzberger, M. B., Cortese, T. A., |r., Sams, W. M., and Wiley, H. S.: Studies on experimental friction blisters. In Sven FHellerstrom 65 years. Acta. Derm. Venereol. (Special Issue) 154, 1966. 13. Akers, W. A., and Sulzberger, M. B.: The friction blister. Milit. Med. 137:1, 1972. 14. Criffin, T. B., Cortese, T. A., Jr., Layton, L. L., and Sulzberger, M. B.: Inverse time and temperature relationship in experimental friction blisters Abstract. Society of Investigative Dermatology, Atlantic City, N), May 3, 1969. 15. Akers, W. A., Leonard, F., Ousterhout, D. K., and Cortese, T. A., Jr.: Treating friction blisters with alkyl-a-cyanoacrylates. Arch. Dermatol. 107:544, 1973. .
