Blistering time as a parameter for the strength of dermoepidermal adhesion: a systematic review and meta-analysis

Skin ageing is associated with a flattening of the dermoepidermal junction and a less effective anchoring system, predisposing to bulla formation, trauma and shear-type injuries. An artificial and controlled technique for standardized dermoepidermal separation is the suction blister method, whereby the strength of dermoepidermal adhesion is characterized by blistering time. To identify and quantify influencing factors on blistering time in healthy humans. A search in the Medline and Embase databases (1946 to June 2014) and in reference lists was conducted. In total, results of 146 suction blister experiments in 3418 individuals reported in 59 publications were analysed. The median blister diameter was 6 mm (IQR 5-6) and the median suction pressure was -210 mmHg (IQR -200 to -300), resulting in a median blistering time of 75 min (IQR 48-120). In the multivariate model, skin temperature and age were the strongest predictors for suction blistering time (P < 0·001, R(2) adjusted  = 0·707). This strong association between temperature and suction blistering indicates that the dermoepidermal junction loses its strength with increasing skin temperature. This finding supports the practice of skin and tissue cooling to prevent injuries. The increased vulnerability of the skin seems to exist irrespectively of applied mechanical loads. We conclude that blistering time is an important and clinically relevant (outcome) parameter measuring the structural and mechanical integrity of deeper cutaneous layers.