|Year : 2020 | Volume
| Issue : 2 | Page : 140-145
Efficacy and safety of treating anogenital warts with intralesional vitamin D3 injection: a report on 20 Egyptian patients
Yasmin M Tawfik1, Ahmed H Hosny2, Amira F El-Gazzar3, Radwa M Bakr1
1 Department of Dermatology, Venereology and Andrology, Assiut University, Assiut, Egypt
2 Department of Andrology and Venereology, Faculty of Medicine, Helwan University, Helwan, Egypt
3 Department of Public Health, Faculty of Medicine, Assiut University, Assiut, Egypt
|Date of Submission||28-Nov-2019|
|Date of Decision||15-Dec-2019|
|Date of Acceptance||12-Jan-2020|
|Date of Web Publication||24-Jul-2020|
MD Yasmin M Tawfik
Department of Dermatology and Venereology, Assiut University, Assiut 71511
Source of Support: None, Conflict of Interest: None
Background Anogenital warts (AGWs) are always resistant to traditional treatment options. Recently, vitamin D3 injection have proven its efficacy in the treatment of extragenital warts. To the best of our knowledge, there are no studies on using intralesional vitamin D3 in the treatment of genital warts.
Aim To evaluate the efficacy of intralesional vitamin D3 injection in the treatment of AGWs.
Patients and methods Twenty patients with AGWs were included in this study. Vitamin D3 (7.5 mg/ml) was injected into the base of the warts every 2 weeks for 2 months.
Results Only two (11.11%) patients showed complete resolution; six (33.33%) patients showed moderate response, while 10 (55.55%) patients showed mild response. Recurrence has been obtained in moderate and mild responders; no adverse effects were observed.
Conclusion The efficacy of using intralesional vitamin D3 in the treatment of AGWs is not as effective as its role in extragenital warts.
Keywords: anogenital warts, genital warts and vitamin D, immunotherapy
|How to cite this article:|
Tawfik YM, Hosny AH, El-Gazzar AF, Bakr RM. Efficacy and safety of treating anogenital warts with intralesional vitamin D3 injection: a report on 20 Egyptian patients. Al-Azhar Assiut Med J 2020;18:140-5
|How to cite this URL:|
Tawfik YM, Hosny AH, El-Gazzar AF, Bakr RM. Efficacy and safety of treating anogenital warts with intralesional vitamin D3 injection: a report on 20 Egyptian patients. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Aug 9];18:140-5. Available from: http://www.azmj.eg.net/text.asp?2020/18/2/140/290602
| Introduction|| |
Anogenital warts (AGWs) are highly infectious; viral inoculation is higher in thin mucosal surfaces than the thick keratinized one, in addition to lesions of coital friction in both sexes . AGWs result in high levels of psychological and social morbidity, in addition to causing pain and discomfort . There are several treatment options, which may be painful and sometimes not effective . Many available destructive therapies have been used such as cautery, either chemical, electric, or with liquid nitrogen, and also excision and laser vaporization, but with high recurrence rate and they do not offer a guarantee of cure as well.
In recent years, intralesional immunotherapy have been tried where intralesional tuberculin purified protein derivative, measles, mumps, and rubella vaccine (MMR) , and Candida albicans antigen have been injected. The mechanisms of immunotherapy have not been explained, it is thought that it may activate the host immune system against the virus, to get rid of warts .
Aktas et al.  used intralesional vitamin D3 for the first time to treat plantar warts with reported encouraging results. However, its efficacy in AGWs have not been studied yet. The exact mechanism of vitamin D3 activity against warts is not completely understood. Vitamin D3 has the ability to regulate proliferation and differentiation of epidermal cells and modulation of cytokine production ,.
Activation of human macrophages by toll-like receptors causes upregulated expression of vitamin D receptor and vitamin D-1-hydroxylase genes, with the induction of antimicrobial peptide and modulation of innate immunity . Experimental evidence suggests that vitamin D can cause modulation of the immune system by inhibiting the expression of cytokines such as interleukin‑6 (IL-6), IL-8, tumor necrosis factor-α, and tumor necrosis factor-γ which are mediated through vitamin D receptor-dependent pathway present in many immune cells and in keratinocytes, melanocytes, and fibroblasts .
The aim of our study was to report the efficacy and safety of intralesional vitamin D3 injection among a group of Egyptian patients with AGWs.
| Patients and methods|| |
A total of 20 patients with AGWs were recruited in this study. The patients were selected randomly from the Outpatient Clinic of the Department of Dermatology, Venereology and Andrology, Assiut University Hospital during the period between June 2018 and April 2019. A written consent was signed by every patient after explaining them the details about the nature and the possible side effects of the study. The study was approved by the ethics committee at Assiut University Hospital.
Patients with one or more AGWs, otherwise apparently healthy and untreated for the past 4 weeks, were included in the study. Pregnant, lactating women and those with any evidence of immunosuppression including HIV and a prior history of hypersensitivity to vitamin D were excluded.
All patients were diagnosed clinically. The duration of the disease, number, site, and size (diameter by millimeter) of the lesions were documented for each patient.
Each lesion was injected with a maximum total amount of vitamin D3 of 1 ml (7.5 mg) in each session; a 21-G syringe was used to inject 0.25 ml of vitamin D3 (7.5 mg/ml) solution slowly at the base of each wart. A maximum of 1 ml solution was used in one session.
Injections were done every 2 weeks for a maximum of four injections, and the patient was followed up for recurrence after 6 months. Patients were photographed at baseline and evaluated for treatment efficacy and adverse reactions, number, and size of lesions every 2 weeks for first 2 months and monthly thereafter for 6 months.
Grading of response according to Raghukumar et al. 2017 :
Complete clearance: 100% of all the warts both treated and distant resolved completely.
Moderate response: if there were 50 to less than 100% reductions in both size and number of lesions.
Mild response: was considered if response less than 50%.
Analyses were conducted using SPSS software (version 18.0; SPSS Inc., Chicago, Illinois, USA). Descriptive statistics such as mean, SD, and percentages were calculated. Data were checked for normality using the Shapiro–Wilk test and were found to be non-normally distributed (P<0.05). Mann–Whitney was used for nonparametric data. c2 was used for categorical data. Correlation was used to assess the association between sociodemographic variables, number, site, and size of lesions and treatment response. P values less than 0.05 were considered statistically significant.
| Results|| |
A total of 20 patients were included in the study. The study included nine women and 11 men. Patients’ demographic data are shown in [Table 1]. Mean ages of the patients were 31.5±9.8 years. A total of 326 lesions were treated. The mean number of lesions was 16.3 with a range from 3 to 35. Duration of warts ranged from 1 to 10 months. Lesion diameters ranged from 2 to 40 mm with a mean of 15.6 mm.
According to the site of lesions, 15 (75%) patients had genital warts; two (10%) had perianal warts; and three (15%) had both genital and perianal.
Two patients had stopped treatment after the first session, while 18 patients completed the treatment sessions. After four treatment sessions, only two (11.11%) patients showed complete resolution ([Figure 1] and [Figure 2]), six (33.33%) patients showed moderate response to treatment ([Figure 3]), while 10 (55.55%) patients showed mild response.
|Figure 1 (a) A male patient with genital warts before treatment; (b) complete response after four treatment sessions.|
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|Figure 2 (a) A male patient with genital warts before treatment; (b) complete response after four treatment sessions.|
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|Figure 3 (a) A male patient with genital warts before treatment; (b) moderate response after four treatment sessions.|
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No correlations have been obtained between the patients’ age, sex, and the treatment response.
In comparing the site of lesions to treatment response, no differences haves been obtained between response to treatment in the previous three sites, P value more than 0.05.
Patients have been classified according to the size and number of lesions into four groups ([Table 1]). A negative correlation has been obtained between both size, number of lesions, and the percentage of improvement; P=0.01 and P<0.001, respectively ([Figure 4] and [Figure 5]). However, best results (complete resolution) were obtained in two patients with lesions ranging in size from 1 to 5 mm in diameter and from 1 to 10 in number ([Figure 1] and [Figure 2]).
|Figure 5 Correlation between the number of warts and treatment response.|
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The treatment response has not been affected by the duration of AGWs which ranged from 1 to 10 months, P value more than 0.05.
After a period of 6 months, the two patients with complete resolution did not show recurrence of AGWs, while those with moderate and mild response, the recurrence rate was 66.66 and 70%, respectively.
Regarding complications, all patients complained of pain during injection; 30% showed swelling at the site of injection which resolved within 4–5 days. None of the patients experienced serious local or systemic side effects.
| Discussion|| |
Treating HPV by activating the immune system against it is an active field of investigation. There are several reports on the use of intralesional antigen and vaccine therapies in AGWs such as bleomycin, purified protein derivative, measles, mumps, and rubella, C. albicans, and Mycobacterium vaccine ,,,, but none of them have investigated the efficacy of intralesional vitamin D3.
As far as we know, there are only two reports of two cases of AGWs treated with topical vitamin D3. Rind et al.  have successfully treated an infant case with an AGW with calcipotriene ointment, a vitamin D3 derivative. Egawa  also have reported that daily application of topical vitamin D3 for genital warts of a 74-year-old man has completely cleared the lesions after 4 months.
Vitamin D has many effects on the immune system. It prevents secretion of immunoglobulins by inhibiting proliferation and differentiation of B cells ,. It also suppresses proliferation of T cells  causing shift to a Th2 phenotype ,. It prevents production of Th17 inflammatory cells , and facilitates the production of T-regulatory cells ,, resulting in a decrease of IL-17 and IL-21 which are inflammatory cytokines and increase of IL-10 which is an anti-inflammatory cytokine . So, inhibiting the adaptive immune system responses and increasing the protective innate responses will help to maintain self-tolerance .
To the best of our knowledge, this is the first study on the efficacy and safety of intralesional vitamin D3 in the treatment of AGWs and to study its effect as an immunotherapy.
Twenty patients with AGWs received intralesional vitamin D3 treatment; two patients did not complete the treatment sessions. Only two (11.11%) patients achieved complete clearance after four injections, while six (33.33%) patients showed moderate response and 10 (55.55%) patients showed mild response. Our results are different from those obtained by Aktas et al.  where 16 of the 20 patients treated with intralesional vitamin D3 injection for plantar warts showed complete resolution.
Another study by Kavya et al.  included 42 patients with multiple resistant extragenital warts who have been treated with intralesional vitamin D3 and have completed the 6-month follow-up period. Of these, 23 had palmoplantar warts, 18 had verruca vulgaris, and one patient had filiform wart. In total, 33 of the 42 (78.57%) patients showed complete response, six (14.28%) patients showed moderate response, and three (7.14%) patients showed mild response. Recurrence was observed in one patient with the palmoplantar wart.
In another study by RaghuKumar et al. , 90% showed complete response of resistant extragenital warts; 6.66% showed partial response; and 3.33% showed no response with complete clearance of all distant warts after a mean of 3.66 number of injections. In another study by Kumar et al. , complete clearance was obtained in 29 patients, moderate response in eight patients, and no response in three patients.
Controversies between our results and the previous studies may be attributed to the known differences in HPV genotypes causing AGWs from those causing the other types of warts. There are more than 120 distinct subtypes of HPV; the anogenital tract can be affected with 40 different subtypes . Distribution of these genotypes varies by countries and regions. Moreover, different HPV genotypes may induce different immune responses . Genital warts are caused by HPV subtypes 6 and 11 in 90% of cases .
Singh et al.  reported different immune responses to HPV genotypes 6 and 11 with strong T-cell responses to genotype 6 and weak immune responses to genotype 11. They also observed a significant correlation between clinical presentation, type of lesion, and immune response, which might have therapeutic implications and might explain the different responses which we observed for vitamin D treatment from the previous studies.Unfortunately HPV genotyping could not be done as most of the patients refuse the biopsy, which was a limitation of our study; so we recommend further studies to report the efficacy of intralesional vitamin D3 in different HPV genotypes.
Patients’ age, sex, site, and duration of lesions had no effect on the treatment response, while a negative correlation has been obtained between size, number of lesions, and treatment response, where both patients with complete clearance had a small number of lesions (nine and three lesions) and small diameter of lesions (3 and 5 mm).
Regarding the side effects to treatment, the patient’s only complaint was minimal to moderate pain during injection, unlike the study obtained by Kavya et al.  where adverse effects were seen in 80% of patients, but all were minor with no life-threatening complications. Swelling at the site of injection was seen in 78.57% of patients which resolved without any treatment in 4 weeks and dyspigmentation was seen in only one patient.
Another limitation of our study that we did not measure the patient’s serum vitamin D levels before injection. It would be better to measure it in further studies to avoid the possibility of hypervitaminosis D.
In conclusion, although intralesional vitamin D3 has proved its efficacy in extragenital warts; its role as a monotherapy in eliminating AGWs is negligible. So, its efficacy in the treatment of AGWS requires further evaluation as an adjuvant therapy with other lines of treatment in randomized, placebo-controlled, clinical trials with larger number of patients and genotyping of the causative HPV.
Presentation at a meeting: World Congress of Dermatology, Milano, Italy, June 2019.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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