Potassium permanganate / saline soaks in eczema/dermatitis

Potassium permanganate is used in the UK as a topical preparation for the care of wounds in the community and hospital setting

• a licensed medicinal product does not exist in the UK, and it is available as a 'chemical product' either as a solution for further dilution or as a 'tablet' preparation which is dissolved in water to give a topical solution of 0.01% (1 in 10,000)
• intended for external use only and serious harm can occur if ingested (1-6)
  • potassium permanganate is toxic if ingested orally and there have been significant patient safety issues when potassium permanganate concentrate has been inadvertently administered orally or swallowed by patients when left unattended near the patient prior to dilution (6)

British Association of Dermatologists (BAD) indicate (1)

• use of potassium permanganate soaks for weeping or blistering conditions such as acute weeping/infected eczema and leg ulcers
• to access the BAD patient information leaflet regarding use of potassium permanganate soaks then click here

The DermNet NZ describe the baths/soaks being used for infected eczema and blistering skin conditions with pus and/or oozing; wound cleansing, especially weeping ulcers or abscesses; fungal infections such as athlete's foot (2)

A review (3) states:

• main indications for potassium permanganate solution can be described as the management of exuding conditions in the following dermatology or vascular conditions
  • weeping or blistering conditions secondary to eczema or cellulitis
  • weeping or blistering conditions secondary to leg or foot ulcers
    
    
• anecdotal use of potassium permanganate preparations is widespread in the NHS for the management of weeping or blistering conditions secondary to eczema, cellulitis, leg or foot ulcers, and pseudomonas infections of the skin/wounds
  • postulated to have antiseptic and astringent action
  • a licensed medicinal potassium permanganate does not exist in the UK and a chemical compound is used for medicinal purposes
  • a Patient Safety Alert was issued in 2014 and since then incidences of patient harm continue to be reported in the NHS
• there is a lack of published evidence for the use of potassium permanganate preparations to aid the management of weeping or blistering conditions secondary to eczema, cellulitis, leg or foot ulcers, and pseudomonas infections of the skin/wounds
  
  
• there were limitations cited in the review (3) including:
  • this Q&A sought only to provide the published evidence base and does not make any recommendations on the use of potassium permanganate in clinical practice or its place in therapy
  • a fundamental reason to the limited discussion of potassium permanganate in the published literature may be due to its classification as a chemical rather than a medicine

Safety concerns (4,5)

Risk of death or serious harm

• AnNHS England patient safety alert from 2022 highlights the risk of death or serious harmfrom accidental ingestion of potassium permanganate preparations. Despite the alert, serious medication errors continue to be reported via the National Reporting and Learning system (NRLS)
  • a Patient Safety Alert issued in 2014 highlighted incidents where patients had inadvertently ingested the concentrated form, and the risks in relation to terminology and presenting tablets or solution in receptacles that imply they are for oral ingestion, such as plastic cups or jugs
  • a review of the National Reporting and Learning System over a two-year period identified that incidents of ingestion are still occurring. One report described an older patient dying from aspiration pneumonia and extensive laryngeal swelling after ingesting potassium permanganate tablets left by her bedside. Review of the other 34 incidents identified key themes:
    • healthcare staff administering potassium permanganate orally
    • patients taking potassium permanganate orally at home, or when left on a bedside locker
    • potassium permanganate incorrectly prescribed as oral medication
  • suggested actions:
    • actions to be completed by 04 Oct 2022
      • 1. Review the overall use of potassium permanganate at trust/area drug and therapeutics committee to consider if the benefit outweighs the risk
      • 2. Unless eliminating the use within the trust/locality, ensure procedures/guidelines for use of potassium permanganate align with all BAD recommendations, including:
        • a) In primary care:
          • patients are not on repeat prescriptions for potassium permanganate (A)
          • prescriptions include clear instructions to dilute before use
          • dispensing label includes the warning 'HARMFUL IF SWALLOWED'
        • b) In secondary care:
          • remove all stock supply (except for use within outpatient departments) and supply on a named patient basis only
          • potassium permanganate is prescribed as ‘potassium permanganate 0.01% topical solution’ and the dispensing label must include the warning 'HARMFUL IF SWALLOWED'
          • potassium permanganate is not stored with medicines for oral/internal use, including the ward drug trolley; dilution should occur away from the patient, and neither the concentrated form or the diluted form, should be left near the patient.
        • c) All settings:
          • prescriptions are only issued by an appropriate prescriber
          • if potassium permanganate is to be used in a patient’s home, a risk assessment must be undertaken before prescribing
          • all patients must be supplied with a patient information leaflet
      • Notes:
        • A. A retrospective risk assessment of primary care patients is not necessary if the action to eliminate repeat prescriptions is taken, but will be necessary when a new prescription is required
        • B. Discussions are ongoing with manufacturers to improve labelling and packaging of potassium permanganate products and remove the use of the term 'tablet'.
        • C. The use of potassium permanganate in wound care has been identified as a strategic research need by the national patient safety team
• 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
  • ensure your organisation is compliant with the NHS England patient safety alert.
  • refer to the Best practice guidance from the British Association of Dermatologists

Notes:

• potassium permanganate stains the nails and skin brown

Reference:

• British Association of Dermatologists. Patient Information leaflet - how to use potassium permanganate soaks. October 2015.
• DermNet NZ. Potassium permanganate, 2006
• NHS Specialist Pharmacy Service (August 2019). What is the evidence for the use of potassium permanganate preparations?
• NHS Specialist Pharmacy Service (November 2021).Using potassium permanganate for skin conditions or wound care
• National Patient Safety Alert - NHS England & NHS Improvement (April 5th 2022). Inadvertent oral administration of potassium permanganate
• Drug and Therapeutics Bulletin 14 November 2022. Minimising risk of harm from potassium permanganate soaks.