CLINICAL FOCUS
Moisture in wound healing:
exudate management
Caroline Dowsett
Dr Caroline Dowsett is Nurse Consultant Tissue Viability, East London NHS Foundation Trust
 Email: carolinedowsett@fsmail.net
T he role of moisture in wound healing has often
been misunderstood. When the science of wound
healing began to develop in 1962 with Winter’s
work on moist wound healing (Winter, 1962), the concept
of moist wound healing became popular. Moist wound
healing has been shown to improve healing, reduce pain
and discomfort and reduce infection rates (Winter, 1962;
Eaglestein et al, 1988; Newmeth and Eaglstein, 1991;
Agren et al, 2001; Wiechula, 2003). It was assumed that
because contact with wound fluid was beneficial to the
healing process in acute wounds, the same approach should
be applied to chronic wounds. It is now known that
chronic wound fluid contains substances detrimental to cell
proliferation, and maintaining contact between a chronic
wound and its fluid is likely to delay healing (Cutting and
White, 2002).
Acute and chronic wound exudate
Exudate is mainly water, but it also contains electrolytes,
nutrients, proteins, inflammatory mediators, protein
digesting enzymes such as matrix metalloproteinases
(MMPs), growth factors and waste products, as well as cells
such as neutrophils, macrophages and platelets (Cutting,
2004). The production of wound exudate occurs as a result
of vasodilation during the early inflammatory stage of
Abstract
Wound exudate can have a significant impact on patient’s quality of life
and delay wound healing. It is also challenging for clinicians and can
be costly in terms of clinical time and dressing cost. Understanding the
difference between acute and chronic wound fluid is essential in order
for clinicians to select the most appropriate treatment for their patients.
Good patient assessment is the starting point for successful management
and should include assessment of the patient, their wound and the type
and amount of exudate. The management pathway should aim to address
contributory factors, improve the patient’s quality of life, optimise the
wound bed and ensure the correct level of moisture at the wound bed.
Dressings and topical negative pressure therapy are the main option for
managing exudates and selection should be based on their clinical and
cost effectiveness. A structured approach to exudate assessment and
management as outlined in this article will help to reduce complications
such delayed wound healing, prolonged treatment and patient suffering.
KEY WORDS
w Wound exudate w Assessment w Management w Dressings
S6
healing under the influence of inflammatory mediators
such as histamine and bradykinin (Trengove et al, 1996).
Acute wound fluid supports the stimulation of fibroblasts
and the production of endothelial cells as it is rich in
leukocytes and essential nutrients (Katz et al, 1991). This
presents as serous fluid in the wound bed and is part of the
normal wound healing process in acute wounds.
However, chronic wound fluid has been found to have
high levels of proteases, which have an adverse effect on
wound healing by slowing or blocking cell proliferation,
particularly of keratinocytes, fibroblasts and endothelial cells
(Schultz et al, 2003). Increased levels of protoelytic enzymes
and reduced growth factor activity all contribute to a
poorly developed extracellular wound matrix. This in turn
affects the ability of the epidermal cells to migrate across
the surface of the wound to complete the healing process.
Understanding these differences between acute and chronic
wound fluid is essential in order for clinicians to select the
most appropriate treatment for their patients.
If a wound bed becomes too dry, a scab will form
that then impedes healing and wound contraction. The
underlying collagen matrix and the surrounding tissue at
the wound edge becomes desiccated (Dowsett and Ayello,
2004) (Figure 1). If a wound produces excessive amounts of
exudate, the wound bed becomes saturated and moisture
leaks out onto the periwound skin causing maceration and
excoriation (Figure 2). A dry wound can be painful for the
patient and a wound that is too wet can lead to saturated
clothing, causing discomfort and distress for the patient.
The challenge for clinicians is to create an environment at
the wound bed that optimizes the wound healing process.
Patient assessment
A number of factors that can influence the production of
exudate. The patient’s underlying condition, the pathology
of the wound and the dressing selection all affect exudate
production (Dowsett, 2008). Therefore, good patient
assessment is the starting point for successfully managing
wound exudate. Assessment should include:
w A full and detailed assessment of the patient
w The impact of wound exudate on the patient’s quality of
life
w Assessment of the wound
w Assessment of the periwound skin
w Assessment of the type and amount of exudate
w Assessment of the current dressing regime and its effec-
tiveness at managing exudate.
Wound Care, June 2011
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Patients with leg ulceration and underlying venous

hypertension are more prone to excess exudate, as are
those with ulcers of inflammatory origin such as pyoderma
gangrenosum (World Union of Wound Healing Societies
(WUWHS), 2007). Increased exudate production is also
seen in patients who spend long periods of time with their
legs dependent and have an open wound, and patients
with congestive cardiac failure and peripheral oedema.
The size and site of the wound as well as its position will
also influence the amount of exudate production, with
larger wounds and sinus or fistula producing more exudate
(Dealey, 1999). If a wound produces excessive amounts of
exudate, and this is not controlled, the wound bed becomes
Figure 1. Dry wound with scab
saturated and moisture leaks out onto the periwound skin,
causing maceration and excoriation (Cutting and White,
2002). Macerated skin, recognizable by its whitish soggy
appearance (Figure 3), will break down easily and can result
in an increase in the overall size of the wound.
Exudate can have a considerable impact on a patient’s
quality of life, and this should be assessed on an individual
basis to ensure a patient-centred approach (Dowsett, 2008).
For many patients, excess exudate can lead to problems of
leaking, soiling of clothes, pain, discomfort and malodour
(Franks and Moffatt, 1998; Price and Harding, 2000). This
problem can have a profound practical and economic
effect on individuals’ daily lives and social interactions, for
example by necessitating frequent laundering of clothes,
linen and furnishings. Pain, fatigue and bulky dressings
can make it difficult for patients to bathe or change their
clothes, leading to frustration and anger (Walshe, 1995). Figure 2. Exuding wound
Inappropriate wound management and dressing selection
can also contribute to the problem; for example, applying
a dressing designed to absorb high levels of exudate to a
low to moderately exuding wound may cause a ‘drawing’
pain, or may adhere to the wound bed causing pain and
trauma on removal as delicate healing tissue is damaged
(Hollinworth, 1995). If a dressing product or therapy used
does not manage the exudate and strike-through (leakage
of exudate through a dressing) occurs, this can lead to
an increased risk of infection. However, it must also be
remembered that an increase in wound exudate may be
an indication of infection (Cutting and White, 2005).
Furthermore, when adhesive products are being removed
too often due to an increased frequency of dressing change,
this can result in damage to the surrounding skin through
epidermal stripping (Cutting, 2008).

Assessment of exudate
Assessment of exudate is an important part of wound
management. The type, amount and viscosity of exudates
should be recorded and dressings selected based on the
characteristics of the exudate. A user-friendly validated tool
specifically for assessing exudate is currently not available.
In the absence of such a tool, it is recommended best
practice that clinicians examine the colour, consistency,
odour and amount of exudate as outlined in Table 1
(WUWHS, 2007).
Figure 3. Maceration in periwound skin
Exudate management
The aim of wound management is to achieve a moist, but
not macerated wound bed. Effective exudate management
must aim to:
w Treat the underlying contributory factors
w Identify patient concerns and improve quality of life

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exudate. Patients with underlying venous hypertension

Effective exudate will require compression therapy. Dressings and devices
management
should be used in the context of a patient care pathway
approach, and selection should be based on their clinical
Prevent and treat
and cost-effectiveness. When selecting a dressing, it is
Treating the
exudate related underlying cause important to remember that the dressing should be able
problems
to manage the exudate in such a way as to enhance the
wound environment to favour healing as opposed to
simply mopping up exudate. Consideration should be
given to the volume of exudate and the viscosity, as some
dressings absorb a higher volume of fluid than others.
Some dressings have the ability to hold the fluid in the
Remove/maintain/ Improve patient
increase moisture quality of life dressing, preventing reflection of fluid back onto the skin
and reducing the risk of maceration. The condition of
the surrounding skin is important in managing exudate,
Optimise the as vulnerable skin can react to excess exudate and cause
wound bed maceration, excoriation and irritant dermatitis (Cutting
and White, 2002). Zinc oxide and petrolatum ointments
have traditionally been used to protect the periwound area,
Figure 4. Pathway for the management of wound exudate (WUWHS, 2007)
but skin barriers and protectants are now frequently used.
They are flexible and easy to use and provide visualization
Table 2. Factors to consider when selecting a dress-
ing for exudate management of the underlying skin (Sibbald et al, 2003).
Understanding the exudate-handling properties of
Absorbs and retains exudate Clinically effective
wound dressings and the recommended wear time is
Prevents leakage and maceration Cost effective essential when caring for these patients. Skin reactions,
Reduces pain Does not require frequent change such as sensitivity and contact dermatitis, are often
Comfortable and conformable Easy to apply and remove caused by inappropriate dressing selection and insufficient
Acceptable to the patient Available across care settings dressing changes (Sibbald and Cameron, 2001). If moisture
imbalance is not corrected, there will be delayed wound
Adapted from Dowsett, 2008
healing, which increases the risks of infection, the demand
w Optimize the wound bed on nursing time and the costs of dressings and other
w Remove, maintain or increase moisture using dressings treatments (Vowden and Vowden, 2004). Choosing the
or devices, depending on the amount of exudate present correct dressing from the start of treatment that deals
in the wound with the problem and prevents complications, such as
w Prevent and treat exudate-related problems (Figure 4). maceration and possible skin stripping, is essential. When
Successful management should aim to treat contributory management plans fail, patients may lose confidence in the
factors, for example through good diabetic control and care provided and this can lead to a lack of concordance.
the use of compression therapy for venous hypertension There are many characteristics of an ideal wound
(Schultz et al, 2003). It is important to measure the dressing, which include maintaining moisture balance
impact of a wound on health-related quality of life, as and effectively removing excess fluid from the wound
not all patients will respond in the same way to a wound bed (Thomas, 2008). Dressing choice will be determined
where exudate is a problem. Research shows that health mainly by the ability of a dressing to achieve the desired
professionals rate the importance of this aspect of care exudate levels to assist healing and prevent exudate-related
differently from the patient themselves (Slevin et al, 1988). problems, such as maceration. A number of other factors
It is important, therefore, to evaluate the treatment plan also need to be considered, see Table 2.
from the patient’s perspective. It is also essential to optimize For many patients, the ideal wound dressing is one that is
the wound bed by debriding wounds, recognizing and not bulky and that ensures a pain-free dressing change and
treating infection and appropriate choice of wound less treatments. Where patients and/or carers are changing
dressing that favours a moist but not macerated wound their own dressings, ease of application and removal are
bed. The wound should be evaluated at each dressing essential dressing qualities because complexity may lead
change and wound exudate levels recorded. As wounds to patients being more dependent on the clinicians and
heal the level of exudate gradually decreases, and the hinder patient empowerment.
exudate management plan will need to change accordingly. For some patients with highly exuding wound the use
of topical negative pressure therapy may be appropriate in
Dressings order to achieve an optimum wound-healing environment.
In local wound management, dressings and topical negative Negative pressure wound therapy has been shown to
pressure therapy devices are the main option for managing reduce the frequency of dressing changes and increase

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Table 1. Assessing exudate

wound and surrounding skin. It should be remembered
Characteristic Possible cause that inappropriate wound management could compound
Significance of exudate colour problems such as pain and leaking of exudate. A good
Clear, amber Serous exudate, often considered ‘normal’ management plan should aim to treat the underlying cause
but may be associated with infection of the problem, identify and manage patients’ concerns and
Cloudy, milky or creamy May indicate the presence of fibrin optimize the wound bed. Modern wound dressings have
strands or infection the ability to actively manage wound fluid, keeping it away
from the wound so as to prevent maceration and promote
Pink or red Due to the presence of red blood cells and
indicating capillary damage faster wound healing. Dressing choice will be determined
mainly by the ability of the dressing to achieve the desired
Green May be indicative of bacterial infection
exudate levels to assist healing and prevent exudate-
Yellow or brown May be due to the presence of slough or related problems. The dressing that is chosen should be
material from a fistula
comfortable and acceptable to the patient.  BJCN
Grey or blue May be related to the use of silver con-
taining dressings Agren MS, Karlsmark T, Hansen JB, Rygaard J (2001) Occlusive versus air exposed
Significance of exudate consistency on full thickness biopsy wounds. J Wound Care 10: 301–4
Cutting KF, White RJ (2002) Avoidance and management of peri-wound macera-
High viscosity High protein content due to infection or tion of the skin. Professional Nurse 18(1): 33–6
inflammation Cutting KF, White RJ (2005) Criteria for identifying wound infection – revisited.
Ostomy Wound Management 51(1): 28–34
Necrotic material Cutting KF (2004) Exudate: Composition and functions. In:White, R (ed). Trends in
Enteric fistula Wound Care:Volume III. Quay Books, London: 41–9
Cutting KF (2008) Impact of adhesive surgical tape and wound dressing on the skin,
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topical preparations Dealey C (1999) The Care of Wounds. A Guide for Nurses. 2nd Edition. Blackwell
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Conclusion
Wound exudate has a significant impact on patients’ quality
of life and can prove challenging for clinicians caring for
the patient. Recognizing the difference between acute and
chronic wound fluid is essential for successful treatment.
Assessment should focus on the patient as well as the
key points
w Chronic wound fluid is detrimental to wound healing
wWound exudate can have a significant impact on patient’s quality of life
wInappropriate treatment can delay wound healing
wA structured approach to assessment and management of exudate is
essential to improve patient outcomes and prevent complications.
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Trengove NJ, Langton SR, Stacey MC (1996) Biochemical analysis of wound fluid
from non-healing and healing chronic leg ulcers. Wound Rep Regen 4: 234–9
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