| |

Received: 14 August 2018    Revised: 8 October 2018    Accepted: 20 February 2019

DOI: 10.1111/jocd.13272

ORIGINAL CONTRIBUTION

Comparative clinical study of the efficacy of intralesional MMR

vaccine vs intralesional vitamin D injection in treatment of
warts

Dalia R. Shaldoum MBBCh1 | Ghada F. R. Hassan MD2  | Eman H. El Maadawy MD2 |
Gamal M. El-Maghraby MD3

1
MBBCh. Faculty of medicine, Tanta
University
2
Dermatology and Venereology, Faculty of
medicine, Tanta University, Tanta, Egypt
3
Pharmaceutical Technology, Faculty of
pharmacy, Tanta University, Tanta, Egypt
Correspondence
Ghada Fawzy Rezk Hassan, 1 Asmaa bent
Abi-Bakr street, Neseem street, end of
Moheb street, Al-Mahalla Al-Kobra, El-
Gharbia, Egypt.
Email: ghadafawzy53@yahoo.com
Abstract
Background: Many therapeutic modalities were reported for the treatment of warts;
however, no single treatment is completely effective.
Objective: To evaluate the efficacy of intralesional injection of MMR vaccine vs vita-
min D in treatment of warts.
Patients and Methods: A total of 60 patients were included in the study divided
into two groups. Group A received intralesional MMR vaccine into largest wart, and
group B received intralesional vitamin D3 into each lesion with maximum of five
warts treated in one session. A maximum of six sessions was done every 3 weeks in
both groups. Follow-up was done for 6 months for any recurrence.
Results: In group A: complete response in 80%, partial response in 6.67%, minimal
response in 6.67%, and no response in 6.67% of patients. About 60% of patients
with multiple warts showed complete clearance of distant untreated warts. In group
B: complete response in 66.7%, partial response in 6.67%, minimal response in 20%,
and no response in 6.67% of patients. There was no significant difference between
both groups. No recurrence was observed in both groups in the follow-up period.
Conclusions: Immunotherapy by both intralesional MMR vaccine and vitamin D3 is
simple, well-tolerated, effective, and cost-benefit modalities for the treatment of
warts.

KEYWORDS

MMR, treatment, vitamin D, warts

1 |  I NTRO D U C TI O N
Warts are caused by infection of the epidermis with human pap-
illomavirus (HPV). HPVs are divided into separate genotypes.
Different HPV types may preferentially infect either cornified
stratified squamous epithelium of skin or uncornified mucous
membranes.1 Some warts may spontaneously disappear, while
others persist and can spread on other body sites. 2 Warts can be
painful depending on their location (eg, soles and near the nails)
and viewed as socially unacceptable when located on visible areas
(eg, hands and face). 3
Many destructive and immunotherapeutic treatments that have
variable success rates are available for warts. The current destruc-
tive therapeutic options for cutaneous warts include cryotherapy,
electrocauterization, surgical excision, laser ablation, bleomycin
intralesional injection, topical agents, such as 5FU/salicylic acid,
more recently, topical treatment cantharidin, podophyllotoxin, and
salicylic acid.4 They have their own limitations, such as suboptimal

J Cosmet Dermatol. 2020;00:1–8. wileyonlinelibrary.com/journal/jocd© 2020 Wiley Periodicals, Inc.     1 |

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2       SHALDOUM et al.
efficacy, associated adverse effects, and high recurrence rates in ex-
5
tensive warts.
About immunotherapy, 2 various intralesional antigens that have
been used for cutaneous warts including the measles, mumps, ru-
bella (MMR) vaccine,6 skin test antigens (mumps, candida,7 tricho-
phyton), Bacillus of Calmette and Guerin (BCG) vaccine, tuberculin,
and Mycobacterium w (Mw) vaccine.5 It is postulated to achieve its
result by stimulating a cell-mediated immune response via recruit-
ment of various immune cells (ie, neutrophils, lymphocytes) and re-
lease of cytokines (eg, TNF-α, IL-1, IL-6, IFN-γ, GM-CSF). Though it is
injected intralesionally, the sensitization it produces may also result
in clearance of noninjected distant warts.7 So, mumps-measles-ru-
bella (MMR) vaccine results in regression of warts via immunomod-
ulation and induction of immune system for destroying virus and the
infected host cells.6,8
The vitamin D has multiple physiological and pharmacological
effects mediated by action of the vitamin D receptors (VDRs). VDR
activators have been shown to inhibit cell replication and have im-
munomodulatory properties. It has been suggested that vitamin D
derivatives exert their effects via diverse mechanisms, including reg-
ulation of epidermal proliferation, inhibition of hyperkeratosis, and
induction of apoptosis and anti-inflammatory actions.9-12
2 |  M E TH O DS
The study was approved by the research ethics committee of the
Faculty of Medicine, Tanta University (approval code 30772/02/16).
This study was done on 60 patients with single or multiple warts
(common, plantar, periungual warts) of different durations, not re-
ceived any treatment within 4 weeks before the injection. The par-
ticipants were collected from the Outpatient Clinics, Dermatology
and Venerology Department, Tanta University Hospital. Exclusion
criteria were as follows: patients with other dermatological or sys-
temic diseases, having allergic response to MMR vaccine, with
history of asthma or allergic skin disorders, pregnant or lactating
women, patients with absolute or relative immunosuppression, and
patients of chronic diseases such as chronic renal failure, hepatic in-
sufficiency, hepatitis, and cardiovascular disorders.
All participants were subjected to complete history taking, com-
plete general, and dermatological examination. Patients, who re-
ceived intralesional vitamin D3, were subjected to measurement of
the calcium level in serum each visit. Photographs of the lesion at
initial presentation, at the end of the sessions, and follow-up photo-
graphs after 6 months were obtained.
The patients were divided into group A included 30 patients who
received intralesional MMR vaccine (VACSERA, Egypt, freeze-dried
0.5  mL vial). After dilution with 0.5  mL distilled water, all patients
were directly injected with 0.3  mL of MMR (without presensitiza-
tion) into the largest wart using an insulin syringe at 3-week intervals
until complete clearance or for a maximum six treatment sessions.
Group B also included 30 patients who received intralesional vitamin
D (MPCI.CA, Egypt). Initially, each lesion was injected with 0.1 mL of
mepecaine 3% (ampoule of 1.8 mL). A few minutes later, 0.4 mL of
vitamin D3 (5 mg/2mL equivalent to 20 000 IU cholecalciferol) solu-
tion was slowly injected into the base of each wart using an insulin
syringe. A maximum of five warts were treated per patient in one
session. The maximum total amount of vitamin D3 injected in one
session was 5  mg. Injections were performed every 3  weeks until
complete clearance or for a maximum six treatment sessions.
In both groups A and B, the surface area and number of warts
were noted and lesions were photographed. With follow-up, the
response to treatment and approximate decrease in size of warts
was recorded and history of adverse effects was taken. Complete
response (CR) for complete disappearance of the warts and return
of normal skin markings (100%), partial response (PR) for more than
50% improvement, minimal response (MR) for less than 50% im-
provement, and no response (NR) for stable disease (0%). Resolution
of distant untreated warts was recorded. The percentage of im-
provement ranged from 0% to 100% according to size of regression
of warts. Follow-up was done every month for six months after last
session to detect any recurrence.
2.1 | Statistical analysis
Data were fed to the computer and analyzed using IBM SPSS soft-
ware package version 20.0 (v 16; SPSS Inc, Chicago, IL, USA).
3 | R E S U LT S
All demographic and clinical data of the patients in both groups were
demonstrated in Table 1 with no statistically significant difference
between both groups.
As regarding the response of warts to treatment in the two
groups; Table 2 shows that the occurrence of complete response
was higher in group A (80% of patients reached complete clearance
of warts, Figures 1 and 2) than group B (66.7% of patients showed
complete response, Figures 3 and 4), but there was no significant dif-
ference between two groups. In group A, partial response was found
in 2 patients, minimal response in 2 patients, and no response in 2
patients. While in group B, partial response was found in 2 patients,
minimal response in 6 patients, and no response in 2 patients. As
regard, the percentage of improvement of warts in the two groups
showed that the percentage of improvement in group A ranged from
0% to 100% with a mean of 88.33 ± 29.62. While in group B, it ranged
from 0% to 100% with a mean of 76.33 ± 37.72. There was no signifi-
cant difference between the two groups regarding the percentage of
improvement (Table 2). In group A, 60% of patients (18) with multiple
warts showed complete clearance of distant untreated warts, while
no improvement in distant untreated warts was found in group B.
Regarding the relation between clinical response and number of
sessions, in group A, there were two patients (6.7%) who showed
complete response after 4 sessions, 12 patients (40%) showed com-
plete response after 5 sessions, and 10 patients (33.3%) showed
SHALDOUM et al. |
      3

TA B L E 1   Demographic and clinical

  Group A(MMR) Group B(Vit D) Test of Sig. P
data of both studied groups
Sex
Male 16 (53.3%) 18 (60%) Χ2 = 0.136 0.713
Female 14 (46.7%) 12 (40%)
Age (y)
≤25 10 (33.3%) 16 (53.3%) Χ2 = 1.222 0.269
>25 20 (66.7%) 14 (46.7%)
Min—Max. 9.0-45.0 14.0-34.0 t = 0.386 0.702
Mean ± SD 25.53 ± 9.96 24.33 ± 6.76
Median 27.0 25.0
Family history
Negative 16 (53.3%) 18 (60%) Χ2 = 0.136 0.713
Positive 14 (46.7%) 12 (40%)
Previous treatment
No 10 (33.3%) 14 (46.7%) 0.556 0.456
Yes 20 (66.7%) 16 (53.3%)
Number of warts
FE
Single 6(20%) 8 (26.7%) 0.186 p = 1.000
Multiple 24 (80%) 22 (73.3%)
Duration (months)
Min.-Max. 3.0-60.0 3.0-60.0 MW = 0.804 0.422
Mean ± SD 14.67 ± 14.54 13.20 ± 15.83
Median 12.0 6.0
Type
MC
Periungual 6 (20%) 6 (20%) 0.305 p = 1.000
Vulgaris 10 (33.3%) 12 (40%)
Plantar 14 (46.7%) 12 (40%)

Abbreviations: FE, Fisher exact for chi-square test; MW, P, P values for Mann-Whitney test; t, P, t
and P values for Student t test; χ2, P, χ2 and P values for chi-square.

complete response after 6 sessions. The patients who showed partial
response reached it after 6 sessions. All other patients who showed
minimal or no response received 6 sessions, so there was no relation
between response and increasing number of sessions. On the other
hand in group B, 14 patients (46.7%) showed complete response after
2 sessions, 4 patients (13.3%) showed complete response after 3
sessions, and two patients (6.7%) showed complete response after 4
sessions. The patients who showed partial response reached it after
six sessions. There was significant relationship between number of
treatment sessions and response in group B (Table 3). There was sig-
nificant difference between the two groups regarding the number of
sessions, as those who received intralesional vitamin D3 needed less
number of treatment sessions to get complete response, Figure 5.
In group A, minimal pain occurred in 24 (80%) patients and min-
imal erythema in 30 (100%) patients. In group B, minimal pain oc-
curred in 20 (66.7%) patients, minimal erythema in 12 (40%) patients,
nail dystrophy in 2 (6.7%) patients with periungual warts, swelling
in 4 (13.3%) patients, and mild symptoms of vasovagal attacks in 8
(26.7%) patients. No significant difference was found between the
two groups except erythema which was significantly higher in group
A. While dystrophy, swelling and vasovagal attack occurred only in
group B. Regarding the recurrence, all cured patients in both groups
did not show any recurrence within the follow-up period which ex-
tended for 6 months after the end of treatment sessions.
There was a statically significant negative correlation be-
tween the response and the number of treatment sessions with P
value = .001* in the group B only (Figure 5), and no statically sig-
nificant correlation was found in group A. There were no significant
correlations between the response and either age, sex, duration of
the disease, or type of warts in each group (Table 4).
4 | D I S CU S S I O N
Cutaneous warts are prevalent conditions in dermatology caused
by the human papilloma virus (HPV). Treatment is almost difficult,
and most of the modalities are destructive resulting in scarring
and are associated with recurrences. Destructive modalities such
as electrical and chemical cautery are painful procedures diffi-
cult to be utilized in children.13 Intralesional immunotherapy by
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4       SHALDOUM et al.

TA B L E 2   Comparison between the

Group A Group B
studied groups according to response and
(MMR) (Vit D)
percentage of improvement
Response (n = 30) (n = 30)    
2 MC
No response 2 (6.7%) 2 (6.7%) χ p 0.889
Minimal response 2 (6.7%) 6 (20%) 1.598

Partial response 2 (6.7%) 2 (6.7%)

Complete response 24 (80.0%) 20 (66.7%)
Min.-Max. 0.0-100.0 0.0-100.0 Z = 0.906 P = 0.365
Mean ± SD. 88.33 ± 29.62 76.33 ± 37.72
Median 100.0 100.0

Note: Z and P values for Mann-Whitney test.

Abbreviations: χ2, P, χ2 and P values for chi-square; MMR, measles, mumps, and rubella; Vit D:
vitamin D.
Statistically significant at P ≤ .05.

A (I) A (II) B (I) B (II)

B (III) B (IV)
A (III) A (IV)

F I G U R E 1   B, Before treatment (group A), male patient aged 27 years old, he had verruca in multiple sites (BI, II, III, IV). T = target wart. A,
After treatment (group A), the same patient after 4 sessions with complete response of target and other distant warts

antigens like BCG, candida, trichophyton, and MMR makes the im-
mune system able to produce a type 1 helper T cell (TH 1)–medi-
ated delayed-type hypersensitivity response to various antigens,
including HPV that accelerates destruction of virus and infected
13
host cells. It can also eradicate the distant wart. Intralesional vi-
tamin D3 may also affect the warts via regulating epidermal cell
10
proliferation and differentiation, inhibiting hyperkeratosis, and
also through effect on different cytokines as vitamin D has im-
mune-regulatory actions.14
In group A (MMR group), 80% showed complete response,
6.67% had partial response, 6.67% had minimal response, and
6.67% had no response. In Nofal et al15 study, complete response
occurred in 63%, partial response in 23%, and no response in 14%,
which was in agreement with the present study. On the contrary,
Na et al 8 recorded only 26.5% of complete response, 25.0% with
partial response, and no response in 48.5%. Lower recorded value
of success of treatment with MMR were also reported in Saini et
al13 where 6.9% showed no response, 22.84% with minimal re-
sponse, 59.77% with partial response, and 26.44% with complete
resolution.
The mean of number of treatment sessions needed in the cur-
rent study to reach complete response was 5.47 ± 0.64 sessions in
group A. But in Nofal et al15 study, the average number of treat-
ments to achieve complete response was 3.25 and 5.38 sessions,
respectively. With agreement with the previous studies, in the
present study, there was no statistically significant relationship
between the therapeutic response to MMR vaccine and the age
of the patients. 8,13,15
SHALDOUM et al.
(B)
(A)
F I G U R E 2   (group A) Female patient aged 32 years old before
treatment (B). Patient after 5 sessions of treatment (A) with
complete response
No presensitization skin tests were done before injections
in the current study in agreement with Saini et al and Nofal et al
13,15 8
studies. However, in the other study of Na et al they tested
patients for existing immunity by intradermal injection of 0.1 mL
of MMR vaccine into the volar aspect of the forearm before
treatment.
The results of the current study showed complete clearance of
other untreated warts in 18 (60%) out of 24 patients who had multi-
ple warts. In agreement with Nofal et al,15 who stated that complete
clearance was observed in 74.5% of those presenting with distant
8
warts. However, in Na et al study, complete clearance was ob-
served in only 24.5% of those presenting with distant warts, and in
the study done by Saini et al,13 70% of patients showed no response
in distant warts.
Mechanism of intralesional injection of antigens may induce a
potent nonspecific inflammatory response toward the cells which is
infected by HPV. It has also been postulated that the trauma itself
may lead to resolution of the wart in individuals with prior sensitiza-
tion. It has been postulated to be related to the release of variable
cytokines like TNF-α, INF-γ, IL-2, IL-4, IL-5, and IL-8. In addition, it
is associated with peripheral blood mononuclear cells proliferation
that enhances Th1 cytokine responses resulting in activation and
hyperproliferation of natural killer cells and cytotoxic T cells that de-
16
stroy cells infected by HPV.
The present study showed tolerable pain in 24 (80%) patients
and erythema in 30 patients (100%). No recurrence was observed
during the six months of follow-up after last session in completely
cured patients in the present study. But in studies performed by
Nofal et al15 and Na et al,8 recurrence was observed in 4.8% and
5.6%, respectively.
|
      5
Also, Horn et al17 studied intralesional immunotherapy using
injection of Candida, mumps, or Trichophyton skin test antigens
efficacy in treatment for warts. There were no differences in re-
sponse among the individual antigens (Candida, 59%; mumps, 51%;
and Trichophyton, 62%; P=.48). There was no difference in response
based on sex. Also, younger age less than 40 years was positively
associated with the probability of response. The average number of
sessions in patients receiving antigen who respond was 5.8 sessions
with 57% with complete resolution of warts, 21% of whom had mul-
tiple warts showed complete clearance of all distant warts. Minimal
side effects were reported as fever, myalgias, edema, and erythema
at the injection site of acral lesions.17
Other study was done by Alikhan et al,7 where intralesional
injection of Candida antigen was used for warts treatment. It re-
vealed that 39% showed complete response, 41% with partial re-
sponse, and 20% had no response. Minimal local reactions like pain,
blistering, and swelling were reported. Patients received a mean
of 4.8 Candida antigen injections in patients showed positive re-
sponse to prior intradermal testing with antigen. Limitation in fol-
low-up was found.7
In group B (vitamin D3 group), 66.7% of patients showed com-
plete response, 6.67% had partial response, 20% had minimal re-
sponse, and 6.67% had no response. Raghukumar et al18 reported
complete response in 90%, partial response in 6.66%, and no re-
sponse in 3.33%. Aktaş et al9 recorded complete clearance in 70%,
15% had a partial response, and 15% showed no response.
Also, Kavya et al19 study revealed complete clearance in 78.57%,
14.28% had a partial response, and 7.14% showed minimal response.
So in the current study, complete response (66.7%) was also lower
as compared with the previous studies.9,18,19 The lower response in
the current study compared to the response of the other studies may
be attributed to the differences in the study population selected for
treatment, the number of the studied patients, duration, and resis-
tance of warts.9,20
In agreement with the previous studies, in the present study,
there was no statistically significant relationship between the
therapeutic response to injection of vitamin D3 and the age of the
patients.9,18,19
No improvement for the distant untreated warts was found in
this group, as injection was done in the base of each wart alone
and with maximal five warts per session with a local anesthetic
agent injected before vitamin D3 injection with 3-week interval
for maximum 6 sessions of treatment. Raghukumar et al18 showed
that the sessions were 3-week interval. But in Aktaş et al, 8 the
maximum number of sessions is only two sessions. However, in
Kavya et al19 the injections were repeated at 2 weekly intervals
for a maximum of four injections with maximal only 2 warts per
session.
The current study recorded that 46.7% of patients showing com-
plete response need only two sessions. The mean of the number of
sessions in the current study was 2.93 ± 0.96 sessions, while it was
3.66 and 3 in the studies done by Raghukumar et al18 and Kavya et
al,19 respectively.
 |
6       SHALDOUM et al.

B (I) B (II) F I G U R E 3   (group B) Male patient

aged 32 years old before treatment (BI,
II). Patient after 3 sessions (AI, II) with
complete response of all warts

A (I) A (II)

Mechanism of action of vitamin D3 was found to have a direct ef- (B)

fect on the regulation of antimicrobial innate responses of immunity
by producing cationic antimicrobial peptides (AMPs) including the
α- and β-defensins and cathelicidins. Also, it stimulates expression of
neutrophils and monocytes. 21
Other possible suggested mechanisms of actions of vitamin D
were by induction of differentiation of epidermal keratinocytes and
apoptosis and inhibition of hyperkeratosis 10 and also serve to immu-
nomodulate different cytokines. Vitamin D inhibits differentiation T
cells. It also inhibits production of interferon-γ, IL-2, and IL-6 which
(A)
are potent mediators of the inflammatory response. Besides, vitamin
D promotes suppressor T-cell activity and inhibits cytotoxic and nat-
ural killer cell formation.14
The present study showed that tolerable pain occurred in 20
patients (66.7%), erythema in 12 patients (40%), nail dystrophy
2 patients (6.7%) with periungual warts, swelling in 4 patients
(13.3%), and mild symptoms of vasovagal attacks in 8 patients
(26.7%).
Raghukumar et al18 showed the same side effects except for nail
dystrophy where mild-to-moderate pain developed in 100%, edema
F I G U R E 4   (group B) Male patient aged 17 years old before
in 3.33%, and mild erythema in 5%. Unlike Aktaş et al9 reported treatment (B). Patient after 2 sessions (A) with complete response
that none of the patients experienced adverse effects, and the only of all warts
patient complaints were of minimal to moderate pain during injec-
tion. But in Kavya et al19 study, all side effects were minor with no The present study showed no recurrence was observed during
life-threatening complications, and swelling was reported in 78.57% the six months of follow-up after last session in completely cured pa-
and also depigmentation in one patient. tients. Aktaş et al9 found the same findings. However, in the studies
SHALDOUM et al. |
      7

TA B L E 3   Comparison between the

Group A Group B
studied groups according to number of
Number of (MMR) (Vit D)
sessions
sessions (n = 30) (n = 30) Test of Sig. P
2 MC
2 0 (0.0%) 14 (46.7%) χ  = 26.966* p < .001*
3 0 (0.0%) 4 (13.3%)
4 2 (6.7%) 2 (6.7%)
5 12 (40%) 0 (0.0%)
6 16 (53.3%) 10 (33.3%)
Min.—Max. 4.0-6.0 2.0-6.0 T = 8.497* <.001*
Mean ± SD. 5.47 ± 0.64 2.93 ± 0.96
Median 6.0 4.0

Abbreviations: χ2, P: χ2 and P values for chi-square test; MC, Monte Carlo for chi-square test; t, P, t
and P values for Student t test; MMR, measles, mumps, and rubella; Vit D, vitamin D.
*Statistically significant at P ≤ .05

TA B L E 4   Correlation between percentage of improvement with

different parameters in each group

Percentage of improvement

Group A (MMR) Group B (Vit D)

  rs P rs P

Age (years) −.035 .903 −.046 .871

Sex (Female) .177 .528 .263 .344
Duration (months) −.410 .129 −.327 .234
Number of sessions −.453 .090 −.786* .001*
Type
Periungual .248 .372 −.460 .085
Vulgaris −.304 .270 .263 .344
Plantar .088 .754 .113 .689

Note: Abbreviations: MMR: measles, mumps, and rubella; r: Pearson

coefficient; Vit D: vitamin D.
*Statistically significant at P ≤ .05.

F I G U R E 5   Correlation between percentages of improvement
with number of sessions in group B
done by Raghukumar et al18 and Kavya et al19 recurrence was ob-
served in 3.33% and in one patient, respectively.
Other study was done by Imagawa and Suzuki,11 where vitamin
D3 derivatives were used topically in treatment of warts in which
local application of (maxacalcitol ointment 25 μg/g) three times a
day was advised. In some cases, the subjects were advised to apply
gauze smeared with approximately a 1 mm thickness of the oint-
ment after a bath and leave it on until they bathed the next day.
In all patients, the warts successfully disappeared within 2 weeks
to 6 months of the start of treatment without pain or other side
effects.
10
Another case report done by Moscarelli et al showed that
local application of activated vitamin D (gauze wet with calcitriol
0.5 μg solution) at least two times a day and the advice to reapply
a gauze wet with calcitriol 0.5 solution after each hand washing led
to disappearance of the wart within three months, without pain or
other side effects and no recurrence within the 9 months since its
disappearance.
According to our best knowledge, the current study is the first
study to compare MMR vaccine and vitamin D3 intralesional injec-
tions as therapeutic options for warts, and from the results, we can
conclude that: MMR vaccine and vitamin D3 intralesional injections
are simple, effective, safe, office technique, well-tolerated, and
cost-efficient modalities in the treatment of different types of warts
even if recalcitrant or multiple. It is easy to administer in outpatient
clinics.
MMR vaccine needed more sessions of treatment to show com-
plete clearance of warts, and clearance of distant untreated warts
was reported, while vitamin D3 needed less number of session treat-
ments to show complete clearance of warts and no clearance of
distant untreated warts were found. Both modalities of treatments
showed a decreased risk of recurrence which is a big problem that
faces both the patients and the dermatologists.
 |
8       SHALDOUM et al.
C O N FL I C T O F I N T E R E S T
The authors declared that there were no conflicts of interest and no
financial support of this work.
ORCID
Ghada F. R. Hassan  https://orcid.org/0000-0001-9131-0263
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How to cite this article: Shaldoum DR, Hassan GFR, El
Maadawy EH, El-Maghraby GM. Comparative clinical study
of the efficacy of intralesional MMR vaccine vs intralesional
vitamin D injection in treatment of warts. J Cosmet Dermatol.
2020;00:1–8. https​://doi.org/10.1111/jocd.13272​