# A comparative study of the therapeutic efficacy of various intralesional immunotherapies in extragenital cutaneous warts

## TL;DR

This study compares the effectiveness of three immunotherapies for treating non-genital warts, finding that the MMR vaccine works best.

## Contribution

The study provides a direct comparison of MMR, BCG, and vitamin D3 as intralesional immunotherapies for extragenital warts.

## Key findings

- MMR showed 90% clearance at injected sites and 80% at distant sites, significantly better than BCG and vitamin D3.
- MMR had a faster and more effective response with a mean clearance time of 5.3 weeks.
- Vitamin D3 had the highest pain rate (80%) and no recurrence observed during follow-up.

## Abstract

Cutaneous warts are caused by human papilloma virus (HPV). Most of the current removal modalities are ablative which is associated with recurrence and scarring at the site. Immunotherapy can overcome these limitations, and also distant warts can be treated simultaneously.

To compare the efficacy of three immunotherapeutic agents, measles-mumps-rubella (MMR) vaccine, Bacillus Calmette Guerin (BCG) vaccine, and vitamin D3 injection in the treatment of multiple extragenital cutaneous warts and to assess the safety and recurrence rates of different intralesional immunotherapeutic agents.

Sixty patients with extragenital cutaneous warts were enrolled in the study and randomized into three groups: Group A: MMR (0.5 mL of reconstituted MMR vaccine); Group B: BCG (0.1 ml BCG); and Group C: vitamin D3 (0.5 mL Inj. vitamin D3 600,000 IU; 15 mg/ml). A target wart was selected, and the intralesional injections were given at a three-week interval for a maximum of five doses. The response was observed in target and distant warts. Adverse effects were noted. Cases were followed up monthly for two months.

The baseline characteristics were comparable across MMR, BCG, and vitamin D3 groups. MMR showed significantly higher complete clearance at both injected (90%) and distant (80%) sites compared to BCG (60%, 40%) and vitamin D3 (25%, 20%) at the final follow-up. MMR was significantly superior to vitamin D3 (p=0.002) in injected warts and in distant warts (p=0.03) at last follow up. Intention-to-treat analysis and Kaplan-Meier survival confirmed a faster and more effective response with MMR (mean 5.3 weeks). Hazard ratios indicated a 95% and 99% lower probability of clearance with BCG and vitamin D3, respectively, compared to MMR. Pain was the most common adverse effect, being highest in vitamin D3 group (80%). There was recurrence in 3 cases in the MMR group, recurrence in 1 case and no recurrence in the vitamin D3 group upon follow-up.

The intralesional MMR vaccine was found to be significantly more effective than BCG and vitamin D3 in treating extragenital cutaneous warts. This makes immunotherapy a promising modality for the treatment of multiple and recalcitrant extragenital cutaneous warts.