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A different balance of cell types is found in chronic wound fluid, where there appears to be an imbalance between the amount of degradative substances such as the matrix metalloproteinases (MMPs) and their inhibitors, tissue inhibitors of matrix metalloproteinases (TIMPs).

The resulting high levels of MMPs not only actively break down protein but also have an inhibitory affect on growth factor activity (Trengrove et al, 1999; Yager and Nwomeh, 1999).

This damage may be maceration (caused by the trapping of fluid on the skin), or excoriation related to the proteolytic enzymes contained within the exudate, however, in practice these frequently occur together.

Damage may also occur due to increased frequency of dressing change, when adhesive products are being removed too often causing epidermal stripping.

Falanga (2000) proposed the terms; none/mimimal, moderate amounts and very exudative, while Sibbald et al (2000) used scant, moderate and copious as descriptors.

While practitioners may believe they understand these terms, Thomas et al (1996) showed that even highly experienced practitioners were unable to objectively estimate the amount of exudate or agree on whether the amount was low, moderate or high.

A more objective measure was proposed by Mulder (1994) who suggested that the amount can be estimated based on the frequency of dressing change using a 10cm x 10cm gauze as the measure.

Although similar terminology is used (absent, minimal, moderate and high), each of these descriptors is quantified (see Box).

While moisture is necessary for healing, an overly wet environment may damage the wound bed as well as the surrounding skin (Cutting and White, 2002).Although it is generally believed that exudate plays an essential role in the healing process it is less clear when its detrimental effects begin to outweigh the benefits.Several studies have investigated the content of exudate and it is apparent that the constituents and quantities of individual components vary among individuals and at different times during the healing process (Baker and Leaper, 2000).In addition to the uncertainty about the constituents of exudate there is also a lack of consensus as to what is the normal amount, with considerable differences occurring between wound types.This problem is compounded by a lack of standardised terminology with regard to exudate and the fact that many practitioners use subjective descriptions of the amount.

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They also demonstrate why it may be difficult to use levels of exudate to predict changes in healing status, as it is not clinically possible to differentiate between exudate and fluid seepage from severe oedematous legs.

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