The Efficacy of Super-oxidised Hydrogel and Solution Compared

to Potassium Permanganate Dressing for the Management of

Cellulitis

Sabrina Ab Wahab

,Tarita Taib

, Rohna Ridzwan

Dermatology Unit, Faculty of Medicine, Sungai Buloh Campus, Universiti Teknologi MARA, Sungai Buloh, Selangor,

Malaysia

Department of Dermatology, Selayang Hospital, Selayang, Malaysia

Keywords: super-oxidised hydrogel, super-oxidised solution, potassium permanganate dressing, cellulitis, local

inflammation

Abstract: Cellulitis causes local residual inflammation which delays clinical resolution. Studies have shown that super-

oxidised hydrogel and solution improves skin and soft tissue infection. This is a multicentre, prospective,

open-label, comparative clinical study involving adults ≥ 18 years old, efficacy comparison between two

methods of dressing; super-oxidised hydrogel and solution dressing compared to potassium permanganate

dressing, assessment of reduction of local inflammation; erythema, oedema and cellulitis severity score.

Thirty patients with 2 different sites of cellulitis received the super-oxidised hydrogel and solution dressing

(SO Group) and potassium permanganate (KMnO4 Group) wet wrap dressing at different sites of leg for 15

minutes, twice a day reviewed at end-of-treatment (day 3 and/or day 7). SO Group when compared to KMnO4

Group showed difference in percentage of erythema reduction at Day 3 (50.05% vs 30.98%; p=0.001) and at

Day 7 (71.10% vs 59.05 %; p=0.045); with median reduction in limb circumference at Day 3 (1.90 cm vs

0.80 cm; p=0.001) and Day 7 (3.00 cm vs 1.80 cm; p=0.021). Both dressings showed reduction of cellulitis

severity score (total score of 21); with median reduction of score at Day 3 (6.0 vs 5.5; p=0.123) and Day

7(12.0 vs 11.0; p=0.567), and significant difference only in erythema scores (p=0.029). Diabetes mellitus,

bullous type, and disease recurrence were significant associated factors. In conclusion, super-oxidised

hydrogel and solution is more effective in improving local erythema and oedema compared to potassium

permanganate dressing, in patients with cellulitis albeit no difference in the reduction of total cellulitis severity

score.

1 INTRODUCTION

Cellulitis is a common acute bacterial infection

affecting the tissues of the dermis and subcutaneous

tissue (Halpern et al., 2008). However, the residual

local inflammations causes delay in resolution of

clinical signs and furthermore may prolong

hospitalization (Bruun et al., 2016). Super-oxidised

technology is a new concept of management in skin

and soft tissue infections as a result of purified water

and sodium chloride electrochemically processed

solution with neutral pH and used primarily in wound

infections and chronic inflammatory skin disease

(Landa-Solis et al., 2005). Its efficacy as an antiseptic

was observed in vitro by destroying the functionality

of the membrane-bound components of the

microorganism, hence providing anti-microbial

properties (Armstrong et al., 2015).

Subsequently, Medina-Tamayo et al studied on

super-oxidised solution inhibition on mast cells

degranulation, hence exploring its benefits in

localized inflammatory reactions (Medina-Tamayo et

al., 2007). On the other hand, potassium

permanganate dressing has been widely used as a

reliable antiseptic. The most compelling evidence on

cellulitic changes was supported by a randomized

control trial by Jesús et al who reported statistically

significant diminishing extent of cellulitis in diabetic

foot ulcer; 80.9% of those treated with super-oxidised

solution compared to 43.7% in those treated with

conventional antiseptics with p value < 0.01

(Martínez-De Jesús et al., 2007).

Wahab, S., Taib, T. and Ridzwan, R.

The Efﬁcacy of Super-oxidised Hydrogel and Solution Compared to Potassium Permanganate Dressing for the Management of Cellulitis.

DOI: 10.5220/0008150800600063

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 60-63

ISBN: 978-989-758-494-7

Therefore, this study aims to observe the efficacy

of super-oxidised hydrogel and solution in reduction

erythema, oedema and total cellulitis severity score

when used as an adjunct to systemic antibiotics in

cellulitis

2 METHODS

We conducted a multicentre, prospective, open-label,

comparative clinical study between February 2017, and

July 2017 at 2 centres, Pusat Pakar Perubatan Universiti

Teknologi MARA and Hospital Selayang, Malaysia.

After obtaining ethical approval, we enrolled adults

aged 18 years or older with clinical diagnosis of Eron

Class 1 and 2 limb cellulitis with presence of clinical

signs of erythema, warmth and oedema and involving

limbs must have a total surface area of erythema ≥

75cm

We excluded patients diagnosed with necrotizing

fasciitis, abscess or requiring surgical intervention,

known allergy or intolerance to study medications,

burn infections and deep vein thrombosis. Patients in

sepsis with hypotension, with systolic blood pressure <

90 mmHg, acute confusion, tachycardia or tachypnoea

were also excluded. Both methods of dressings were

randomly allocated dressing to either proximal/anterior

or distal/posterior area on the selected limb, in the same

patient.

All patients received the super-oxidised hydrogel

combined with solution dressing and potassium

permanganate (KMnO4) dilution 1:10000 wet wrap at

different areas of the same or different leg for 15

minutes twice a day. Standardized similar 2 pieces of

gauze dressing equal to size of 3-inch length x 6-inch

width at each intervention site. Similar plasters were

used and was marked with a waterproof skin marker.

All measurements were performed with

standardized similar flexible plastic measuring tape.

Cellulitis severity score was used as a clinical

assessment tool adapted from a previous clinical trial

using a numerical value; none =0, mild =1, moderate=

2, and severe =3; based on erythema, warmth,

tenderness, oedema, ulceration, drainage and

fluctuance at the affected area (Hepburn et al., 2004).

Evaluation of the reduction of erythema and

oedema performed by a single investigator, measured

as percentage of reduction of total surface area

erythema; and oedema reduction by reduction in limb

circumference, at end-of-treatment (day 3 and/or day

7). Secondary endpoints include reduction of cellulitis

severity score which measures erythema, warmth,

tenderness, oedema, ulceration, drainage and

fluctuance; at end-of-treatment (day 3 and/or day 7).

Efficacy outcomes were presented as percentages, and

p values were from Mann-Whitney test; Chi square

test compared severity scores; linear regression and

analysis of variance identified potential associated

factors.

3 RESULT

Thirty patients with 2 different sites of cellulitis area

were enrolled and followed up to day 3, subsequently

15 patients received up to 7 days of both dressings.

Baseline characteristics were similar as both

dressings were applied in the same patient. Study

showed that super-oxidised hydrogel and solution

dressing (SO Group) was more effective in reducing

erythema compared to potassium permanganate

dressing (KMnO4 Group), with significant difference

in percentage of erythema reduction at Day 3 (50.05%

vs 30.98%; p=0.001) and at Day 7 (71.10% vs

59.05%; p=0.045).

Super-oxidised hydrogel and solution was also

more effective in reducing oedema compared to

potassium permanganate dressing alone which was

statistically significant, with median reduction in limb

circumference at Day 3 (1.90 cm vs 0.80 cm;

p=0.001) and Day 7 (3.00 cm vs 1.80 cm; p=0.021),

respectively. There was no difference in both dressing

in the reduction of cellulitis severity score (maximum

total score of 21), with median reduction of score at

Day 3 (6.0 vs 5.5; p=0.123) and Day 7(12.0 vs 11.0;

p=0.567) albeit erythema scores

alone showed

significant difference (p=0.029).

Figure 1 Study Flow Chart Figure

Inpatient Cellulitis in PPPUiTM and

Hospital Selayang

The Efﬁcacy of Super-oxidised Hydrogel and Solution Compared to Potassium Permanganate Dressing for the Management of Cellulitis

Variables that showed significant association

identified were diabetes mellitus (p=0.004),

recurrence of cellulitis (p=0.035), or who had bullous

type cellulitis (p<0.001).

4 DISCUSSION

The primary outcome was the significant

reduction of erythema. Our study showed statistically

significant improvement of erythema with super-

oxidised hydrogel and solution dressing compared to

potassium permanganate dressing. After 3 days of

skin dressing, there was significant reduction in

percentage of erythema, SO group vs KMnO4 group;

p=0.001 and those deemed indicated to extend up to

7 days of skin dressing had also significant reduction

in percentage of erythema; p=0.045.

Our findings were supported by previous clinical

trials that had proven the efficacy of super-oxidised

solution. To the best of our knowledge, a randomized

controlled trial by Jesús et al reported diminishing

extent of cellulitis in diabetic foot infections treated

with super-oxidised solution when compared to

conventional disinfectant (p<0.01)(6). Previously,

this novel hydrogel and solution was mainly studied

on wounds, where Pandey et al found statistically

significant decrease in surface area of surgical

wounds when compared to povidone iodine

(p=0.001) (Pandey et al., 2011). This supports the

premise that the super-oxidised hydrogel and solution

dressing is beneficial in cellulitis, and other SSTIs.

Figure 2 Comparison of Erythema Reduction Between SO

Group vs KMnO4 Group

Further evidence demonstrated in our study was

the greater difference in limb circumference between

SO group vs KMnO4 group with median (1.90 cm

(IQR 1.43) vs 0.80 cm (IQR 1.65); p<0.001) at day 3

and day 7 (3.00 cm (IQR 2.30) vs 1.80 cm (IQR 1.90);

p <0.05). We measured the reduction in limb

circumference and noted similar modality previously

used in several studies as an indicator of reduction of

oedem (Caban, 2002; Beasley, 2011; Brindle et al.,

2017). The positive outcome from our study in

cellulitis was the greater reduction in oedema with

super-oxidised hydrogel and solution compared to

potassium permanganate dressing. One study

described greater reduction of wound size and

periwound oedema in the super-oxidised solution

group (70%) when compared to povidone iodine

treated group (50%) (Kapur & Marwaha, 2011) .

We relate that improving oedema will contribute

to resolution of signs. Our findings support the

evidence that super-oxidised hydrogel and solution

reduces oedema as a sign of local inflammation in

SSTIs. Previous literature did advocate compression

dressings to improve oedema in cellulitis (Gunderson,

2011). From our study, both methods of dressing

showed improvement in severity of oedema. These

findings support the benefits of skin dressing in

cellulitis, but more study data is required.

Particular of interest is the similar treatment

response in both methods of dressings by evaluating

the cellulitis scoring. Our data did not show any

significant difference in the reduction of cellulitis

severity score between the two methods of dressing.

Although no statistical differences were noted in the

reduction of score between the groups, the two study

treatments differed in terms of their anti-

inflammatory properties. The possible reason for

comparable cellulitis severity score in both groups

may be due to the difficulty in measuring progressive

overall inflammatory outcomes by clinical signs. Our

findings showed statistically significant improvement

in erythema severity scoring in SO group compared

to KMnO4 group at day 7 with p value 0.029. In

determining the efficacy, based on this finding, it can

be demonstrated that super-oxidised hydrogel and

solution has better control in erythema.

We acknowledge the limitation of open label

study and blinding was impossible due to the different

colour of both dressings. We also took measures to

avoid carryover effect with both intervention and

comparison dressing requiring at least a 2 cm gap

,considered based on Baranoski et al who discussed

on healing ridge (Baranoski & Ayello, 2012). Most

major factors affecting the outcome were controlled

through the exclusion criteria. However, important

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

confounding factors that were unable to be controlled

were diabetes mellitus, bullous type cellulitis, and

disease recurrence that were significantly associated.

5 CONCLUSION

Super-oxidised hydrogel and solution is more

effective in improving local erythema and oedema, as

compared to potassium permanganate dressing, in

patients with cellulitis albeit no difference in the

reduction of total cellulitis severity score. There was

improvement of the overall local inflammation with

intervention by both methods of dressing in this

study.

ACKNOWLEDGEMENT

This study was sponsored by both the investigator and

Dyamed Biotech Sdn Bhd who supplied the study

products. We would like to thank our Head of

Department, Dr Mohd Arif bin Mohd Zim for his

support of this investigator-initiated clinical research.

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The Efﬁcacy of Super-oxidised Hydrogel and Solution Compared to Potassium Permanganate Dressing for the Management of Cellulitis