Complications of Exudate Production
Maceration
Maceration (from the Latin maceration to make wet or soften) is defined as the softening and breaking down of skin resulting from prolonged exposure to moisture (Anderson, 1998). Excessive wound exudate or other bodily fluids, such as urine or sweat, can cause skin maceration around a wound, which may delay healing and lead to other complications (Cutting & White, 2002). Maceration occurs when fluid is present on the skin for long periods. This may be due to a dressing that is not absorbent enough to contain fluid from the wound or in a dressing that does not ‘lock’ the fluid away. The tissues have the appearance of white or pink softened ‘soggy’ skin.
An exuding wound coupled with a wet dressing may increase the fluid loss on to the surrounding skin. Therefore the correct moisture balance - neither too moist nor too dry - at the wound/dressing interface must be achieved (Bishop et al., 2003). Skin should be kept clean and dry to prevent maceration and to protect it and the wound from breaking down further.
Allergic Reactions
It is also possible for a patient to become sensitive to their own exudate (Hampton & Collins, 2003). Patients whose wounds are heavily exuding can develop redness around the wound, even under neutral foam dressings. This is sometimes mistaken as a skin reaction caused by the dressing rather than a reaction to the exudate.
There is a difference in the presentation with contact dermatitis compared to clinical infection, as seen in the table below.
| Infected wounds | Contact dermatitis |
|---|---|
| Erythema | Erythema |
| Swelling, oedema | Swelling, oedema |
| Delayed healing | Delayed healing |
| New or increased pain | Itching, stinging and or burning pain |
| Friable, bleeding wound | Eczema seen, puritis |
| Purulent discharge | Dry skin, hyperkeratosis |
| Wound bed discolouration | Crusting |
| Increased exudate | Oozing from the periwound |
Adapted from (Ewart, 2015, Johnston et al., 2017)
Exudate can, however, cause problems, especially in chronic wounds such as leg ulcers. Because it contains proteolytic enzymes, it can, on exposure to the skin around a wound, provoke excoriation and a ‘contact dermatitis’ reaction (Cameron & Powell, 1992). Clinically, this presents with localised itching, pain, and discrete or diffuse periwound red rash/erythema of varying severity that may delay healing or worsen the wound base and margin despite appropriate treatment (Alavi et al., 2016).
The reaction of inflammation, redness and weeping caused by an allergic reaction may also be mistaken for wound infection.
Additionally, a dressing may have been applied to one area of the body with no sensitivity problems, but when it is applied to another area, a problem arises. This is because the immune system is ‘triggered’ by the first application, with subsequent applications of the allergen causing a skin reaction, which in some cases can be severe (British Association of Dermatologists [BAD], 2009). Allergic contact dermatitis is also referred to as contact sensitivity and is particularly common in patients who have chronic venous leg ulcers (Tavadia et al., 2003; Machet et al., 2004; Saap et al., 2004).