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.[1] Different serotypes of HPV causes morphologically varied clinical presentations such as plane warts, verruca vulgaris, filiform warts, periungual and palmoplantar warts.[2] 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.[9] 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.

RESULTS

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)

DISCUSSION

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[1]. 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 [10] where 80% patients showed complete response and 6.67% showed partial response. In a similar study by Mohta et al [11], 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. [13]

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 [10] 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. [10]

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 [10] 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 [14] 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 [15] where only 2 patients (6.67%) out of 30 patients showed complete clearance. On contrary, Shaldoum et al [10] 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[16], where by using half day occlusive dressing technique, topical vitamin D3 therapy was found to be effective in three immunocompromised individuals. Moscarrelli et al [17] 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 [18] and Singh et al [19] 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. [12]

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. 

LIMITATIONS

The study was limited due to small sample size, short follow-up period and absence of placebo control group.

CONCLUSION

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

None

Source Of Funding

Nil

Ethical conduct of research

The authors declare that this review article does not require Institutional Review Board/Ethics review or approval.

REFERENCES

1. Singh SK, MohanA, Gupta AK, Pandey AK. A comparative study between intralesionalPPD and vitamin D3 in treatment of viral warts; Int J Res Dermatol. 2018;4(2):197-201.

2. Naseem R, Aamir S.The Efficacy of Intralesional Measles, Mumps, Rubella (MMR) Antigen in Treatment of common Warts; PJMS 2013; 7(4):11301133.

3. Gibbs S, Harvey I, Sterling J, Stark R. Local treatments for cutaneous warts: systematic review.BMJ. 2002;325:461.

4. Alghamdi KM, Khurram H. Successful treatment of plantar warts with very diluted bleomycin using a translesionalmultipuncture technique: pilot prospective study. J Cutan Med Surg. 2012; 16:250-6.

5. Kimura U, Takeuchi K, Kinoshita A, Takamori K. Suga Y. Long-pulsed 1064-nm neodymium: yttriumaluminum-garnet laser treatment for refractory warts on hands and feet. J Dermatol. 2014;41:252-7.

6. El-MohamadyAel-S, Mearag I, El-Khalawany M, Elshahed A, Shokeir H, Mahmoud A. Pulsed dye laser versus Nd:YAG laser in the treatment of plantar warts: a comparative study. Lasers Med Sci. 2014;29:1111-6.

7. Cockayne S, Curran M, Denby G. EverT: cryotherapy versus salicylic acid for the treatment of verrucae-a randomised controlled trial. Health Technol Assess. 2011;15:1-170.

8. Bruggink SC, Gussekloo J, Berger MY. Cryotherapy with liquid nitrogen versus topicalsalicylic acid application for cutaneous warts in primary care: randomized controlled trial. CMAJ. 2010; 182:162430.

9. Kavya M, Shashikumar BM, Harish MR, Shweta BP. Safety and Efficacy of Intralesional Vitamin D3 in Cutaneous Warts: An Open Uncontrolled Trial. J CutanAesthet Surg. 2017;10(2):90-4.

10. Shaldoum DR, Hassan GFR, El Maadawy EH, ElMaghraby GM. Comparative clinical study of the efficacy of intralesional MMR vaccine vs intralesional vitamin D injection in treatment of warts. J Cosmet Dermatol. 2020;19(8):2033-40. 

11. Mohta A, Kushwaha RK, Gautam U, Sharma P, Nyati A, Jain SK. A comparative study of the efficacy and safety of intralesional measles, mumps, and rubella vaccine versus intralesional vitamin D3 for the treatment of warts in children. PediatrDermatol. 2020;37:853–9.

12. Kus S, Ergun T, Gun D, Akin O. Intralesional tuberculin for treatment of refractory warts. J EurAcadDermatolVenereol. 2005;19(4):515-6.

13. Nofal A, Nofal E, Yosef A, Nofal H. Treatment of recalcitrant warts with intralesional measles, mumps, and rubella vaccine: a promising approach. Int J Dermatol. 2015;54(6):667-71.

14. Raghukumar S, Ravikumar BC, Vinay KN,Suresh MR, Aggarwal A, Yashovardhana DP.Intralesional Vitamin D3 Injection in the Treatment of Recalcitrant Warts: A Novel Proposition. J Cut Med Surg. 2017;21(4):320-4.

15. Kareem IMA, Ibrahim IM, Mohammed SFF, Ahmed AA. Effectiveness of intralesional vitamin D3 injection in the treatment of common warts: Single blinded placebo-controlled study. DermatolTher. 2019 May;32(3):e12882.

16. Egawa K, Ono T. Topical vitamin D3 derivatives for recalcitrant warts in three immuno-compromised patients. Br J Dermatol. 2004;150:374-76.

17. Moscarelli L, Annunziata F, MjeshtriA,Paudice N, Tsalouchos A, Zanazzi M, Bertoni. Successful treatment of refractory wart witha topical activated vitamin D in a renal transplant recipient. Case Rep Transplant. 2011; 2011:368623.

18. Akula M L, Shetty M, Shetty V, Patel P, Basil A. Comparative study of therapeutic efficacy of intralesional vitamin D3 versus intralesional purified protein derivative in the treatment of warts. IP Indian J ClinExpDermatol 2018; 4(3):226-31.

19. Singh SK, Mohan A, Gupta AK, Pandey AK. A comparative study between intralesional PPD and vitamin D3 in treatment of viral warts. Int J Res Dermatol. 2018;4:197-201.