Jikisha Jain, Kriti Maheshwari, Amandeep Saluja, Kapil Vyas, Kalpana Gupta
Department of Dermatology, Venereology and Leprology, Geetanjali Medical College and Hospital, Udaipur
Warts are the benign proliferation of cutaneous or mucosal epithelium, caused by Human Papilloma Virus (HPV), which are small DNA viruses infecting both keratinized and nonkeratinizedepithelium. Diﬀerent serotypes of HPV causes morphologically varied clinical presentations such as plane warts, verruca vulgaris, ﬁliform warts, periungual and palmoplantar warts. Warts occurs with equal frequency in both gender and mode of transmission is direct or indirect contact. Predisposing conditions for extensive or recalcitrant involvement include atopic dermatitis and impaired cell-mediated immunity.A gamut of therapeutic interventions is available but no one is fully eﬀective. Common approaches include either chemoablative procedures using diﬀerent strengths of salicylic acid, trichloroacetic acid, ﬂuorouracil and bleomycin or physical destruction of aﬀected tissue through cryotherapy, laser or surgical excision.[3-8] Most of these modalities are associated with local site related adverse eﬀects such as ulcerations, scarring hyperpigmentation, and allergic contact dermatitis. Moreover, these therapies are not suitable in the setting of multiple and recalcitrant warts and are associated with recurrences. To address the limitations of destructive modalities, intralesional immunotherapy has evolved as a viable option in the management of warts, that not only cure the local infection but also targets the latent infections and prevent recurrences. The principle underlying immunotherapy in warts is mounting of delayed-type hypersensitivity (DTH) reaction against intralesional antigens as well as the viruses causing warts. Among various intralesional antigens used over a past few years, MMR vaccine has been established as an eﬃcacious intralesional immunotherapeutic agent. Oﬀ late, vitamin D3 has been tried as a topical or intralesional immunotherapeutic agent in management of warts with variable success. Vitamin D3 could not be regarded as antigen and mechanism underlying its immunotherapeutic potential is yet not clear. Its regulatory eﬀect on acquired immunity makes it unlikely to be an immunotherapeutic agent which mount DTH against intracellular organisms. It is postulated that vitamin D activates or train the innate immune system, particularly monocytes and macrophages which in turn increases the production of several natural defensins capable of decreasing the intracellular survival of bacteria and viruses. Although , previous studies has compared the eﬃcacy and safety of intralesional vitamin D3 and MMR but still the evidences are not robust due to various limitations.[10,11] This randomized active controlled trial was planned to compare the eﬃcacy and safety of two immunotherapeutic agents (MMR vs Vitamin D3) with diﬀerent mode of immune stimulation.
MATERIAL AND METHODS
Prior to initiation of the study, an approval from the ethical committee was obtained. The study included 80 patients with morphological diﬀerent warts. The patients were recruited from the outpatient department of our institute over a period of 6 months. Patients have either single or multiple extragenital warts of atleast 12 months’ duration. Few patients had distant warts, present on anatomical site diﬀerent from the wart receiving intralesional immunotherapy. The diagnosis of the wart was made clinically and patients were refrained from using any additional or alternate treatment for warts during the study period. Patients were randomly allocated into two groups by lottery system. The group receiving intralesional MMR vaccine was designated as the group A and the other group receiving intralesional Vitamin D3 was designated as the group B. Neither the patient nor the dermatologist who evaluated the treatment response in both the groups, were aware of the treatment given. In this manner, we could ensure the double blind nature of the study. Thirty patients in each group completed the study, and 20 patients were lost to follow-up. These dropouts were excluded from the ﬁnal analysis. The patients were selected based on inclusion and exclusion criteria.Patients who were willing to undergo the procedure, having single or multiple warts with no concurrent treatment for last three months and were more than 18 years of age were included in the study whereas patients having prior allergic response to MMR vaccine or Vitamin D3, Pregnancy & Lactation, immunosuppression, keloidal tendency or with past history of asthma, smoking, convulsions and anaphylaxis and patients with facial and anogenital warts were excluded from the study. Written informed consent was taken prior to their participation. Baseline characteristics of the warts including number, site, size, duration, and presence or absence of distant warts were noted at the start of the study and thereafter at each follow-up visit.
The patients of group A, were given intralesional MMR vaccine. The freeze dried vaccine was reconstituted with 0.5 ml of diluent and a volume of 0.5 ml was injected with a tuberculin syringe into the wart or into the largest wart in patients with multiple warts. This was repeated every 3 weeks until complete clearance of all the warts or for a maximum of 3 treatment sessions.
In study group B, the patients were injected with 0.5 ml of 15mg/ml (6 lakh IU) of vitamin D3 on the base of wart with the help of tuberculin syringe. Injections were repeated at 3 weeks’ interval till there is complete clearance or maximum of 3 sessions.
Response to treatment was observed by the dermatologist other than the one who carried out the procedure. Responses were recorded as decrease in size or number of warts with photographic documentation of the same. The response was considered Complete if there was disappearance of the wart with appearance of normal skin markings, Partial response if there was 50-99% reduction in the original size of the treated wart. Poor response was labelled when there was less than 50% reduction in the size of wart and No response-no reduction in the size of the wart.
Pre-treatment close up photographs of all patients were taken with Apple IPhone triple 12-megapixel wide lens. They were compared with photographs taken serially after every treatment session and after 6 months of follow up. Immediate or late adverse eﬀects (if any) were noted at each treatment session. Only patients who achieved complete responses in both the groups were observed for 6 months’ post treatment to detect any recurrences.
Statistical analysis: Data were entered, checked, and analyzed using the SPSS/PC (Statistical package for social science for personal computers Ver.21) package. Data were expressed as mean±SD for quantitative variables, and number and percentage for qualitative variables. Chi-square test and F-test were used as appropriate. P-values of <0.05 were considered signiﬁcant.
Sixty patients (30 in each group) completed the study whereas 20 patients lost to follow up and were excluded of the ﬁnal analysis. Baseline clinicodemographic proﬁle of patients of both group were comparable with no signiﬁcant diﬀerence between them (Table 1)
n group A (MMR group) 80% patients showed complete response, 10% showed partial response, 3.3% showed poor response and 6.7% patients showed no response at all whereas in group B (Vitamin D3), complete response was seen in 70% patients, partial response in 16.7%, poor response in 6.7% and no response in 6.7% patients. There was no signiﬁcant diﬀerence between the two groups regarding the response rate. (Table 2 and Figure 1A, 1B, 2A, 2B)
In MMR group, 18 patients (78.2%) out of 23 patients have shown complete clearance of distant warts whereas in vitamin D3 group, only 5 patients (27.7%) out of 18 patients showed complete clearance. There was statistical signiﬁcant diﬀerence in both the groups (p value = 0.0002). Only 2 patients in group A and 5 patients in group B showed recurrence of warts groups after 6 month-follow up period.
No serious side eﬀects were seen in any of our patients in both the groups. Pain and swelling were the two common side eﬀects seen in both the groups and were comparable (p value of 0.19 and 0.29 respectively). In group A, erythema was seen in 14 patients. In 5 patients, warts resolved with post inﬂammatory hyper pigmentation. One patient showed ﬂu like symptoms within 12 hours of injection. None of the extreme side eﬀects such as blistering, scarring, wounding and infections were noted. In group B swelling at the injection site was seen in 14 patients, 9 patients showed mild to moderate itching typically seen after 2-3 days of injection and resolving in 5-6 days. No nail dystrophy with periungual warts and symptoms of vasovagal attack were seen in our study. (Figure 1)
Myriads of treatment modalities are present for treating warts. Destructive modalities are the most commonly used but are associated with pain, disﬁguring scarring and an increase risk of recurrence. Recently, intralesional immunotherapy by diﬀerent antigens has proved eﬃcacy in the resolution of these longstanding benign proliferations. The exact mechanism of immunotherapy is still unrecognized but is believed that it mounts a strong delayed type hypersensitivity response to various antigens when injected into the wart tissue and is found to be associated with the production of Th1 cytokines to eradicate HPV infection. Thus, clears not only the local warts but also distant warts unlike traditional wart therapies. Lately, MMR vaccine and vitamin D3 both have been proved to be excellently eﬃcacious and a safer modality in the treatment of warts and only few studies have been done till now comparing MMR vaccine and vitamin D3 as therapeutic modalities for the treatment of warts. (Table 3)
In the current study, group A (MMR group) 80% patients showed complete response, 10% showed partial response which was in agreement with the study by Shaldoum et al  where 80% patients showed complete response and 6.67% showed partial response. In a similar study by Mohta et al , 86.67% patients showed complete response. This increased response to treatment can be attributed by the fact that this study was done on peadiatric age group where chances on spontaneous resolution of warts is quite higher.It is believed that MMR vaccine helps in mounting a cell mediated immune response against HPV infection as intralesional immunotherapy stimulates the release of various cytokines such as Interleukins 2 & 12, TNF α, IFN γ which generates an immune response. 
In group A, the response rate was independent of age, sex and the duration of the disease. Also in this group, 18 patients (78.2%) out of 23 patients have shown complete clearance of distant warts which was similar to a study conducted by Shaldoum et al  where 60 % patients showed complete distant wart clearance. Our study showed complete clearance of 20 out of 24 multiple warts of which palmoplantar warts showed better improvement.Only 2 patients showed recurrence in six months follow up after the last session.
Vitamin D has multiple pharmacological as well as physiological eﬀects which are mediated by its action on vitamin d receptors (VDRs). It mediates the induction of human beta defensin2, cathelicidin and release of reactive oxygen species. It promotes epithelial cell diﬀerentiation and stimulates apoptosis of keratinocytes. 
In group B (Vitamin D3), our study showed complete response in 70% patients and partial response in 16.7% which was in agreement with the study by Shaldoum et al  where 66.7 % patients showed complete response while 6.67% showed no response at all. A much higher success rate was seen in study by Raghukumar et al  where 90 % patients showed complete response and only 3.33% patients showed no response. Only 5 patients (27.7%) out of 18 patients with distant warts showed complete clearance which was slightly higher than the study by Kareem et al  where only 2 patients (6.67%) out of 30 patients showed complete clearance. On contrary, Shaldoum et al  study has shown no improvement in any cases of distant warts. This can be attributed by the fact that vitamin D has a propensity to enhance local immune response through increase of AMP and its eﬀect on acquired immune arm is usually regulatory therefore does not seem to have value in treating distant wart.Only 5 patients showed recurrence in six months follow up after the last session.
Topical vitamin D3 has also shown promising results. In the study by Egawa and Ono, where by using half day occlusive dressing technique, topical vitamin D3 therapy was found to be eﬀective in three immunocompromised individuals. Moscarrelli et al  demonstrated the disappearance of warts within three months of topical application of vitamin D derivative on warts at least two times a day. Intralesional therapy in the treatment of warts is not a new proposition but encouraged by above studies, we attempted to use intalesional vitamin D solution as the ﬁrst line modality for treating extragenital warts.
To our best knowledge, our study is one of the few to compare the eﬃcacy of MMR vaccine and Vitamin D3 in the treatment of warts. Both the modalities when compared showed similar response rate. The higher response in MMR group can be acknowledged due to the presence of three antigens which accentuates each other’s potential of generating a higher immunogenic response. This fact can be supported by two comparative studies done by Akula et al  and Singh et al  where both compared vitaminD3 and tuberculin PPD intralesionally for warts and found higher response rate with PPD injections. A higher response in MMR group can also be attributed by the fact that trauma itself may induce resolution of warts in previously MMR- sensitised patients. Therefore, MMR vaccine proved to be eﬀective in treating distant warts as compared with vitamin D3. 
The local side eﬀects encountered by both of them were minor and easily controllable. None of the extreme side eﬀects such as blistering, scarring, wounding and infections were noted in both the groups. Risk of recurrence was also greatly reduced by both the modalities.
The study was limited due to small sample size, short follow-up period and absence of placebo control group.
This study concludes that both MMR vaccines as well as vitamin D3 injection are simple, safe, eﬀective, well tolerated, cost eﬃcient, therapeutic modalities that can be added to the armamentarium of treatment options for extra genital and recalcitrant warts. We should avoid unnecessary exhaustion of live vaccine and encourage judicious use of MMR vaccines. Vitamin D can be opt as a good alternative treatment to MMR in various clinical settings as it is much cheaper and easily available in Indian markets.We recommend using intralesional vitamin D as a ﬁrst line treatment modality where warts are singular in nature, where there are palmoplantar warts, in pregnancy, lactation and immunosuppression where live vaccines such as MMR are contraindicated.
Conﬂict Of Interest
Source Of Funding
Ethical conduct of research
The authors declare that this review article does not require Institutional Review Board/Ethics review or approval.
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