Abstract
Genital warts have a big psychological impact on the affected individuals, as the treatment requires time and multiple sessions at a time. They can also increase the chances of acquiring other sexually transmitted diseases. Various treatment options are available including the topical application of imiquimod, podophyllin, trichloroacetic acid application, cryotherapy, and radiofrequency cautery. However, all of these require multiple sessions, and chances of recurrences are high. Some of them also have multiple local side effects as burning, irritation, erythema, and swelling. Overall genital warts represent a frustrating challenge for both patients and physicians. Intralesional immunotherapy has shown promising efficacy in the treatment of warts including the following: Bacille Calmette–Guerin vaccine, candida antigen, Mw vaccine, and measles, mumps, and rubella (MMR) vaccine. We report the two cases of genital warts, who had an excellent response with intralesional MMR vaccine.
Keywords: Genital warts, immunotherapy, intralesional, measles, mumps and rubella vaccine
INTRODUCTION
Genital warts are transmitted by sexual route and pose a significant psychological burden for the patients. At the same time, they can also increase the chances of acquiring other sexually transmitted diseases. Warts can be difficult to treat, and patients usually receive multiple treatments with incomplete clearance. Hence, a treatment which is easy to use has a low side effect profile, and low-recurrence rate is always desirable.
CASE REPORT
Methods
We injected 0.5 ml intralesional measles, mumps, and rubella (MMR) vaccine into the largest wart at 3-week intervals. There was complete clearance in one patient after two sessions. The second patient had only received a single session and had significant improvement. Results in these two patients indicate that intralesional MMR vaccine can be a very simple and effective treatment option for genital warts.
Case 1
A 20-year-old male presented with complaints of painless lesions over genitals for the past 6 months. On examination, there were multiple verrucous papules merging to form large plaques with exophytic growth [Figure 1]. They were located on the glans and dorsal surface of prepuce extending on the penile shaft. The size of the plaques was about 1.5–2 cm in diameter without any erythema, swelling, or tenderness. There was no lymphadenopathy, urethral discharge, or ulceration on the genitals.
Figure 1.
Multiple verrucous papules and plaques with exophytic growth on glans and prepuce
Blood counts, HIV status along with the serological nests for syphilis, herpes, and hepatitis B and C were normal.
We injected 0.5 ml of MMR vaccine divided equally in both glans and prepuce lesion. The patient was followed up every 3 weeks. Lesions started to flatten after first session only [Figure 2] and after the second session, they were completely subsided [Figure 3].
Figure 2.
Significant flattening of lesions at 3 weeks (after the single session)
Figure 3.
Complete clearance at 6 weeks (after the second session)
There were no patient-reported side effects. Only pain during the procedure was noted. The patient was under regular follow-up and there were no recurrences after 6 months.
Case 2
A 50-year-old male presented with numerous verrucous papules over penile shaft, prepuce, and glans [Figure 4]. Warts were covering almost completely the distal third of penile shaft as well as glans and prepuce in the whole circumference for the past 1 year. They were again coalescing to form large growth like the first patient. There were also few discrete verrucous papules over the penile shaft and scrotum.
Figure 4.
Verrucous papules over the penile shaft, prepuce, and glans
Blood counts and other serological tests, including HIV, Hepatitis B and C, VDRL, and HSV, were negative.
Again 0.5 ml of MMR vaccine was given intralesionally in both the glans and prepuce lesions divided equally.
After first session only, almost all lesions were subsided after 3 weeks except few discrete ones over the penile shaft [Figure 5]. Unfortunately, the patient lost to follow-up after that.
Figure 5.
Almost complete clearance at 3 weeks (After a single session)
DISCUSSION
Genital warts are almost always sexually transmitted. They are the source of extreme discomfort and anxiety for the patients. Results with currently available treatment options are usually disappointing and chances of recurrences are usually quite high.[1]
Considering all the shortcomings of currently available treatments as previously described, search for a treatment for genital warts which is ideal regarding the ease of administration, low inside effect profile, and with minimal recurrence is always on.
Intralesional immunotherapy in the form of Mw vaccine, tuberculin, mumps, or candida antigens with favorable results has been tried in the past. Out of these, Gupta et al. have conducted a study which has shown complete clearance of the lesions in eight out of nine patients.[2,3] Other studies were done either with mumps/candida antigen by Clifton et al.,[4] or with tuberculin (purified protein derivative) by Kus et al.,[5] on the patients with extragenital warts. There are no case reports of MMR vaccine use for genital warts.
The mode of action of intralesional antigen immunotherapy is not completely known. Intralesional immunotherapy was found to be associated with the release of various cytokines such as interleukins 2 and 12, interferon-gamma, and tumor necrosis factor-alpha that can initiate a strong immune response against human papillomavirus.[6] Strong host cell-mediated immunity is always required for successful intralesional antigen immunotherapy.[7]
Flu-like symptoms, which might be due to inflammatory cytokines in response to the vaccine antigens, have been seen as the most common side effect in previous studies with immunotherapy for warts.[6] We did not notice any side effects in both patients except the pain during the injection.
The lesions had complete clearance after three sessions in the first patient and near complete clearance after only a single session in the second patient.
CONCLUSION
MMR vaccine can be a very effective option if given early during the course of disease as has been proven in few of the studies published earlier in the literature. However, it has not been tried for genital warts as far as we know and searched for in literature.
We recommend to use this therapy early in the course of disease, which can save the patient of some psychological stress and physicians of some long, repeated cumbersome treatment options.
Further studies in larger sample population will help in establishing this mode of therapy as a regular one.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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