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.
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:
- Solutions for further dilution (available from special-order manufacturers)
Using for skin conditions or wound care
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.
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 potassium permanganate’s classification as chemical rather than a medicine.
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.
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.
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
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.
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.
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.
Alliance Pharma. Personal Communication. February 2019.
Bus SA, van Netten JJ, Lavery LA et al. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. Diabetes Metab Res Rev 2016; 32(s1):16-24.
Delgado-Enciso I, Madrigal-Perez VM, Lara-Esqueda A et al. Topical 5% potassium permanganate solution accelerates the healing process in chronic diabetic foot ulcers. Biomedical reports 2018; 8(2):156-159.
DermNet NZ. Leg ulcer. 2004.
European Dermatology Forum (EDF) Guideline Subcommittee Diagnostics and Treatment of Venous Leg Ulcers. S3 Guideline on Venous Leg Ulcer. J Eur Acad Dermatol Venereol 2016; 30(11):1843-1875.
Game FL, Apelqvist J, Attinger C et al. IWGDF guidance on use of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 2016; 32(s1):75-83.
George SMC, Karanovic S, Harrison DA et al. Interventions to reduce Staphylococcus aureus in the management of eczema. Cochrane Database of Systematic Reviews 2019, Issue 10. Art. No.: CD003871. DOI: 10.1002/14651858.CD003871.pub3.
International Diabetes Federation. Clinical Practice Recommendation on the Diabetic Foot. A guide for health care professionals: International Diabetes Federation, 2017.
Joint Formulary Committee. British National Formulary (online). London: BMJ Group and Pharmaceutical Press [cited 09/2021].
Hansson C, Faergemann J. The effect of antiseptic solutions on microorganisms in venous leg ulcers. Acta Dermato-Venereologica; 1995; 75:31-33.
Lipsky BA, Berendt AR, Cornia PB et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. IDSA Guidelines. Clinical Infectious Diseases 2012; 54(e132):e173
NICE Clinical Knowledge Summaries. Cellulitis – acute. Scenario: Managements of acute cellulitis. Updated January 2021 [cited 09/2021]
NICE Clinical Knowledge Summaries. Eczema – atopic. July 2021. [cited 09/2021].
NICE Clinical Knowledge Summaries. Leg Ulcer- Venous. August 2021. [cited 09/2021].
NICE. Clinical Guideline 168 Varicose veins: diagnosis and management. Updated July 2013[cited 09/2021]
NICE Clinical Knowledge Summaries. Venous eczema and lipodermatosclerosis. Updated: February 2020. [cited 09/2021].
NICE. NG 19 Guideline on diabetic foot problems: prevention and management. Updated Oct 2019. [cited 09/2021].
Martindale: The Complete Drug Reference. Potassium Permanganate. London: Pharmaceutical Press [cited 09/2021].
Quartey-Papafio CM. Lesson of the week: importance of distinguishing between cellulitis and varicose eczema of the leg. British Medical Journal 1999; 318(7199):1672-1673.
Registered Nurses’ Association of Ontario (2013). Assessment and Management of Foot Ulcers for People with Diabetes (2nd ed.). Toronto, ON: Registered Nurses’ Association of Ontario. [cited 09/2021].
Royal College of Nursing. clinical practice guidelines.The management of patients with venous leg ulcers. June 2013.
Wahab SA, Talib T. Diabetic lower-extremity infection: clinical outcome of super-oxidised hydrogel and solution as a novel adjunctive treatment for cellulitis. Journal of Diabetes Investigation 2018; 9(Suppl. 1):93.
- Updated with NHSEI National Patient Safety Alert April 2022 and British Academy of Dermatologists guidance 2022.