About potassium permanganate

Potassium permanganate is used as a topical preparation for the care of wound or skin conditions in the community and hospital setting. Potassium permanganate is classed as ‘an oxidising agent’ which is thought to confer bactericidal properties.

Regulatory status

A licensed medicinal potassium permanganate product does not exist in the UK. It is only available as a ‘chemical product’.

Potassium permanganate is subject to the Control of Substances Hazardous to Health Regulations. This includes separate storage, additional hazard labelling, and issue only to staff and patients who have been educated to understand its safe use.

Products and preparations

The chemical product is dissolved in water to give a topical solution of 0.01% (1 in 10,000). This is applied as wet dressings or used as a bath soak. Products available are:

• Tablets for cutaneous solution:
  • EN-Potab 400mg tablets for cutaneous solution (Ennogen Healthcare Ltd)
  • Permitabs 400mg tablets for cutaneous solution (Alliance Pharmaceuticals Ltd)
• Solutions for further dilution (available from special-order manufacturers)

Using for skin conditions or wound care

Indications

The indications are not described uniformly in the medical literature and potassium permanganate’s place in therapy remains ambiguous.

The BNF describes diluted potassium permanganate as a mild antiseptic and astringent, which can be used for cleansing and deodorising eczematous reactions and wounds.

According to the medical literature it is usually used for dermatology or vascular conditions, such as:

• Weeping or blistering conditions secondary to eczema or cellulitis
• Weeping or blistering conditions secondary to leg or foot ulcers

Anecdotally, it is also sometimes used in practice for Pseudomonas infections of the skin/wounds.

Clinical guidelines

Guidelines do not offer potassium permanganate as a treatment option for weeping or blistering complications related to dermatological or vascular conditions. Guidelines reviewed are listed in the bibliography.

For venous leg ulcers, the Royal College of Nursing, NICE CKS (and other bodies) conclude there is generally a lack of evidence for different cleansing methods, including topical antiseptic wound cleaners, in preventing infection.

For the management of eczema, a recent Cochrane review (2019) was unable to provide any definite clinical practice guidance for reducing Staphylococcus aureus, due to insufficient evidence. Although NICE CKS guidance briefly discuss that antiseptics (including potassium permanganate) can be used to lower bacterial load in atopic eczema, they don’t provide any further advice on their place in therapy.

Published studies or case reports

Evidence is lacking on the benefits of potassium permanganate solutions for weeping or blistering complications related to dermatological or vascular conditions.  Only one small study in people with diabetic foot ulcers and a couple of old case reports found a positive outcome. The limited data available in the literature may be due to potassium permanganate’s classification as chemical rather than a medicine.

Dermatological conditions

For lower limb cellulitis in diabetic patients, potassium permanganate soaked dressings were found not to be as effective as super-oxidised hydrogel and solution dressing, in a small open-label study (n=21). A reduction of erythema was evaluated as a sign of improvement of local inflammation. The study found a statistically significant difference was seen at day 3 in favour for super-oxidised hydrogel and solution dressings compared to potassium permanganate soaked dressings (57% vs. 37%; p=0.007).

Two old case reports (1999), with little reporting detail, suggest some positive outcome in people with varicose eczema of the legs who were successfully managed with a combination of potassium permanganate solution 1:10,000 and topical steroids, resulting in the leg rash clearing and discharge to home.

Vascular conditions

A small, single-blind RCT (n=24) found topical potassium permanganate solution accelerated the healing process of chronic diabetic foot ulcers and improved some outcomes such as the size of ulcer area (by 73%). All people in the study had superficial or deep (often infected) ulcers but with no abscesses; it is not clear if the ulcers were weeping or blistering.

A small microbiological study from 1995 (n=29; ulcers=45) found the mean number of bacteria per ulcer (including Pseudomonas species) did not significantly reduce with application of potassium permanganate solution on venous leg ulcers. A range of antiseptic solutions were studied and only acetic acid showed a statistically significant response.

Safety concerns

Risk of death or serious harm

NHS England/Improvement issued a National Patient Safety Alert on the inadvertent oral administration of potassium permanganate in April 2022.  This alert highlights that serious medication errors continue to be reported via the National Reporting and Learning system (NRLS), despite an NHS England alert in 2014 highlighting the risk of death or serious harm from accidental ingestion of potassium permanganate preparations

Accidental ingestion

All patients who have ingested any amount of potassium permanganate should be referred urgently to hospital. Refer to Toxbase (subscription required) for further information on toxicity, features and management of toxicity.

Adverse effects

Skin contact

Potassium permanganate can cause skin irritation, redness, pain, burns and skin hardening on contact with the dry crystals or concentrated solutions . Staining of skin can be experienced even with dilute solutions.

Eye contact

Inadvertent exposure of the eye to dry crystals (including crystal dust) or concentrated solutions can cause irritation, blurred vision, redness, staining of the conjunctiva, swelling of the eyelids and local burning.

Actions to minimise risk of harm

• Review the use of potassium permanganate preparations in your organisation in light of the evidence base described above and consider if the benefit outweighs the risk.
• Ensure your organisation is compliant with the the National Patient Safety Alert (2022): Inadvertent oral administration of potassium permanganate. Healthcare settings are required to complete actions by 04 October 2022:
  • Assess if the use of potassium permanganate can be reduced.
  • Ensure safer prescribing and labelling.
  • Ensure safe storage.
• Refer to the 2022 guidance from the British Association of Dermatologists: Recommendations to minimise risk of harm from potassium permanganate soaks. This includes advice on
  • Formulary management, prescribing, dispensing, labelling, storage, preparation and use, and waste.
  • Information on risk assessment if the product is to be used in a persons home. It is recommended that a
    documented record should be kept with agreed mitigating actions; the risk assessment does not need to be a formal document.

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