Journal of Clinical and Aesthetic Dermatology

MAY 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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19 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY May 2018 • Volume 11 • Number 5 O R I G I N A L R E S E A R C H reduced adverse effects and lower recurrence rates have been reported with this therapy. 13 In the present study, significant difference in therapeutic response was observed between the MMR and control groups. A study done by Nofal et al 14 also reported a significant difference in results between patients receiving MMR injection and those receiving placebo. In Nofal's study, 81.4 percent patients showed complete clearance of warts with minimal side effects. These findings were slightly better than the results of our study, where complete clearance was observed in 68 percent of the patients who received MMR injection. Similar to Nofal et al's 14 observation, Zamanian et al 15 also observed a higher response (75%) to MMR injection compared to our study. Saini et al 16 observed a lower rate of complete clearance (46.5%) with MMR injection (Table 7). Demographic distribution and other clinical variables such as the number and site of warts did not alter the therapeutic response to MMR injection. In a study done by Horn et al, 15 immunotherapy with single antigens (mumps) yielded a 54-percent response in patients. Use of the three antigens —measles, mumps, and rubella— together help in eliciting a stronger immune response against HPV through the production of various cytokines like interleukin (IL)-2, IL-4, IL-5, and tumor necrosis factor-α. In the present study, 68-percent complete clearance was seen with a mean number of 3.7±1.0 injections. Comparable results were seen in the study by Singh et al 17 where a 54.5-percent complete response rate was achieved with a mean number of 3.4±1.1 injections. Singh et al 17 also emphasized the activation of Th1 response with immunotherapy, which was effective for treating not only injected warts but also distant warts. In a study by Dhakar et al, 18 significant clearance was seen in distant warts with the use of Mycobacterium vaccine immunotherapy when compared to cryotherapy. In another clinical trial, 19 78 percent of patients showed clearance of anatomically distant warts with mumps and Candida immunotherapy. Maximum complete clearance was seen in palmoplantar warts (70.9%). Palmoplantar warts are comparatively resistant to other treatment modalities. In our study, patients with palmoplantar warts were more in number, owing to treatment resistance compared to other types of warts; hence, better response was seen with this particular type. This was in contrast to complete remission seen in Verruca vulgaris (66.7%) with Mycobacterium indicus pranii vaccine immunotherapy. 20 Immunotherapy with MMR antigen has been shown to be a safer modality than other options, without precipitating any serious adverse effects. Pain during injection and flu-like symptoms were common side effects reported by the patients included in our study. These findings were comparable with various other studies. 15,19,20 A 2.7-percent recurrence rate in the MMR group and a six-percent rate in the control group were seen in our study. This was in contrast to the studies done by Nofal et al 14 and Zamanian et al 15 where no relapse was seen. In a study by Johnson et al, 19 relapse occurred in two percent of patients who received mumps antiserum. Limitations. Although the MMR vaccine appears to be a promising immunotherapy agent, certain limitations exist. Due to lack of resources, our investigators were not blinded, as there would have been difficulties in the assessment of efficacy and safety of the therapeutic agent used. The role of the MMR vaccine in the treatment of anogenital warts, warts in children, and warts in pregnant women was not evaluated in this study. Lastly, the follow-up period of our study was only 16 weeks from the last injection. Longer follow-up periods are necessary in order for more meaningful conclusions to be drawn. CONCLUSION Immunotherapy with MMR intralesional injection has therapeutic potential as a safe and effective treatment modality for cutaneous warts. It is a simple, cost-effective, and non-destructive method that has shown efficacy and good tolerability. With less side effects and a lower relapse rate compared to other treatment modalities, MMR immunotherapy can potentially be used as a first-line treatment for warts. TABLE 5. Response of distant and recalcitrant warts in MMR and control groups T YPE OF WART MMR GROUP CONTROL GROUP DISTANT WARTS n=54 n=37 Complete response, n (%) 26 (48.0) 9 (24.0) Good response, n (%) 14 (26.0) 7 (19.0) Moderate response, n (%) 9 (17.0) 7 (19.0) Mild/no response, n (%) 5 (9.0) 14 (38.0) DISTANT WARTS n=38 n=28 Complete response, n (%) 9 (24.0) 5 (18.0) Good response, n (%) 15 (39.0) 8 (29.0) Moderate response, n (%) 9 (24.0) 6 (21.0) Mild/no response, n (%) 5 (130) 9 (32.0) n: number TABLE 6. Adverse effects ADVERSE EFFECTS MMR GROUP (N = 72) CONTROL GROUP (N = 50) Pain during injection 65 (90%) 44 (88%) Headache and rhinitis (flu-like symptoms) 5 (6%) 1 (2%) Edema/erythema/itching after injection 3 (4%) 0 (%) Infection/wound formation/scarring after injection 0 (%) 0 (%) n: number TABLE 7. Comparison between various studies STUDY ANTIGEN RESULTS STUDY GROUP CONTROL GROUP Nofal et al. 14 MMR Complete response: 81.4%; No response: 8.6% Complete response: 27.5%; No response: 57.5% Zamanian et al. 15 MMR Complete response: 75%; No response: 8.3% Complete response: 27.3%; No response: 31.8% Saini et al. 16 MMR Complete response : 46.5%; No response: 32.6% No control group Singh et al. 17 Mycobacterium indicus pranii Complete response: 54.5%; Mild response: 6.8% No control group Present study MMR Complete response: 68%; Mild/no response: 6.9% Complete response: 10%; No response: 60% MMR: measles, mumps, and rubella

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