Initial management options. For intact blisters, if the blister is small, nontense, and not located in a joint area, I recommend leaving the blister intact. Endogenous inflammatory mediators may decrease the area of injury, similar to burn care,1 while providing a natural protective biologic dressing. The blister should be covered with a nonadhesive, silicone outer dressing. Large, tense, or over-the-joint blisters should be punctured in 1 to 2 spots with a large bore angiocath to allow decompression, with care not to deroof the blister. The area should be checked every shift to initiate timely management once the blister opens, at which time it should be gently debrided.
If there is an open wound, my first preference is medical-grade (active Leptospermum) honey (ALH) in the form of gel or a honey-impregnated hydrocolloid. For a very superficial wound, an amorphous hydrogel also works well. ALH features are important for the open wound: 1) acidic pH, which decreases bacterial colonization and improves oxygen diffusion; 2) hyperosmolarity, which facilitates autolytic debridement by increasing lymph flow and decreases bacterial proliferation; 3) the ability to decrease pro-inflammatory modulators and proteases, and 4) antimicrobial properties via hydrogen peroxide and methylglyoxal production. These characteristics facilitate extracellular matrix deposition by promoting fibroblast migration, proliferation, and organization of collagen and angiogenesis while supporting slough minimization.2
Addressing slough. Slough is common in extravasation wounds; at times, it requires a stronger debriding agent. Collagenase (the only enzymatic debrider approved in United States) is perfectly safe to use in neonates, especially in hard slough. Collagenase hydrolyzes peptide bonds and digests all triple helical collagen; it will not degrade any other proteins lacking a triple helix. Collagenase starts at the lower portion of an eschar, working from the bottom up and softening the area, facilitating autolytic debridement, especially in combination with an eschar cross-hatching. Concentrated surfactant gel is another excellent choice for softer slough. Studies support its wound-stabilizing properties (by inserting zeta potential in cell membrane), potentially minimizing the area of necrosis. Surfactant gel lifts necrotic tissue via the principles of amphiphilicity (ie, it possesses both hydrophilic and lipophilic properties) and micelle formation.
Debridement. Most wounds do not need sharp debridement, but mechanical debridement can be helpful. I like using a monofilament debrider pad or lolly; these are single-use debriding devices composed of monofilament polyester fibers.3 This debrider should be generously moistened with normal saline before use to minimize pain and facilitate necrotic tissue removal. It is well-tolerated, even by children, and works fast.
Bioengineered skin products. Most wounds heal well with topical honey, gel, atraumatic dressings, and gentle care. Recalcitrant wounds require more advanced dressings. Acellular matrices incorporating collagen have produced good results, acting as a scaffold for new cells and a deterrent for wound proteases while contributing to native collagen to improve extracellular matrix generation.4
A variety of amniotic membrane-based dressings are available and include dehydrated, cryopreserved, amnion-only, and amnion/chorion-based products.5 I have had good experience with dehydrated amniotic membrane allografts; soft, malleable, and easy to work with, these dressings are excellent for neonatal wounds. For bigger, deeper wounds, a cryopreserved version (often combined with umbilical cord-based products) can be considered. Amniotic membrane grafts offer a scaffold, provide anti-inflammatory mediators, promote cellular differentiation and adhesion, suppress infection suppression, support neovascularization, and exert a potentially scar minimizing effect.
Not much literature exists on the use of epidermal, dermal, or composite allografts, but several case reports describe their efficacy in deep extravasation wounds. The general principal of replacing like tissue with like tissue makes sense in deeper, more advanced wounds.
Negative pressure. All the above-mentioned products can be supported by using negative pressure wound therapy (NPWT). I often use single-use, portable negative pressure devices — they do not require foam, are easy to operate, facilitate discharge, and employ evaporation along with negative pressure as a work mechanism. Many NPWT systems use traditional, foam- and/or canister-based units. The innate healing potential of neonatal skin responds beautifully to the supportive structure these products offer.