European Journal of Cardiovascular Medicine

Warts or Verrucae are benign tumors and are one of the common cutaneous viral infections caused by human papilloma virus[1]. Patients may seek therapy for pain, discomfort, or cosmetic issues caused by these conditions. The primary objective of wart therapy is to eradicate the wart, prevent its reappearance and disfigurement, and assist the body's immune system in curing the infection and offering lifelong defense against the viral infection.

Given the availability of several treatment options, effectively managing warts can be often challenging, particularly when they are widespread and unresponsive to treatment. Warts may necessitate diverse treatments depending on their type and location.  Immunotherapy has been increasingly used in recent years to treat warts, and the outcomes have been promising. Therefore, this study was conducted to report the efficacy of intralesional Vit. D3 in treating cutaneous warts.

This study includes a cohort of 30 patients with warts who attended the Dermatology, Venereology, and Leprosy Outpatient Department (DVL OPD) at SVRRGG Hospital in Tirupati from February 2021 to January 2022.

Inclusion Criteria: 1. Patients who gave informed and written consent. 2. Patients aged between 12 and 60 years were included in the study.

Exclusion Criteria: 1. Pregnant and lactating women. 2. Prior history of hypersensitivity to Vit. D3 injection or lignocaine. 3. Evidence of immunosuppression including HIV and patients with keloidal tendency were excluded.

Methodology:

Patients were initially evaluated upon their first visit, and their demographic information was recorded.

The location, quantity, sizes, and classifications of warts in each patient were documented during every appointment.

Photographs were captured throughout every visit to provide visual evidence for the recorded data. When there were several warts, only the larger warts, with a limit of 2, were treated during each session.

Vitamin D3 for injection is available in the form of an ampoule containing 600,000 units of cholecalciferol in 1 ml (equivalent to 15 mg).

Initially, the selected warts were administered with 0.2 ml of lignocaine by injection. After a short period of time, 0.2 ml of Vitamin D3 injection was administered slowly into the base of each wart using a 27g insulin syringe. The injections were administered at intervals of 2 weeks for a total of four sessions or until complete clearance, whichever occurred first.

Table 1: Age Distribution

The mean age in the present study was 27 years. The maximum number of patients were in the age group of 21-30 years (46.67%).

Table 2: Sex Distribution

               In the present study, males (63.33%) constituted majority of the study population. The male to female ration was 1.72:1.

Table 3: Distribution of Patients by Duration of Warts

               Most of the patients in the present study (53.33%) had warts for duration between 7-12 months. The mean duration was 8.13 months.

Table 4: Distribution of Different Types of Warts

               The most common type of wart in the present study was common warts (56.67%) followed by palmoplantar warts (33.33%), filiform warts (6.67%) and periungual wart (3.33%).

Table 5: Distribution of Patients Based on History of Treatment Taken in the Past

               In the present study, the majority of the patients had no history of treatment in the past (63.3%).

Table 6: Distribution Based on Number of Warts

               In this present study, the majority of patients (73.33%) had less than 5 number of warts. The mean number of warts was 3.83%.

Table 7: Results of Intralesional Vitamin D3 Injection

               The complete response in the present study was seen in 66.67% of patients. The partial response and no response were seen in 10% and 23.33% of patients, respectively.

Table 8: Time Taken for Resolution of Warts

The minimum and maximum duration taken for the resolution of warts in the present study was 2 weeks and 8 weeks, respectively. The mean duration for the resolution of warts was 5.65 weeks.

Table 9: Complications Observed in Intralesional Vitamin D3 Injection

The most common complication seen in the present study was swelling at site of injection in 36.67% patients followed by dyspigmentation (6.67%).

Figure 1: At baseline visit

Figure 2: complete resolution seen at 6 weeks (3^rd visit)

COMMON WARTS

Figure 3: At baseline visit

Figure 4: complete resolution at 6 weeks (3^rd visit)

PALMAR WART

Figure 5: At baseline visit

Figure 6: complete resolution at 8 weeks (4^th visit)

Age Distribution:

In this present study, the mean age was 27 years. The minimum age was 13 years and the maximum age was 58 years. The maximum number of patients were in the age group of 21-30 years (46.67%). This is similar to observation made by Priya et al [2], Banoth [3], Garde et al [4] and Potlapati et al [5]. In contrast to the present study, Singh et al observed 0-20 years of age group constituted the maximum number of patients in their study.

Sex Distribution:

Males (63.33%) constituted majority of the study population in this present study. The male to female ratio was 1.72:1. This is comparable to similar studies done by Potlapati et al[5], Singh et al[6] and Kavya et al[7]. This ratio is little less when compared to studies done by Priya et al[2], Verma et al[8] and Garde et al[4]. This ratio is more when compared to study done by Abdel-Azim et al[9]. Reason for the male preponderance may be due to their increased outdoor activities in addition to the increasing trend of cosmetic concern.

Duration of Warts: 

Most of the patients in this present study (53.33%) had warts for duration between 7-12 months. The minimum and maximum duration were 1 month and 24 months respectively. The mean duration was 8.13 months. This is almost similar observation made by Verma et al[8]. The mean duration was less in comparison to studies done by Potlapati et al[5] and Raghukumar et al[10] and more in comparison to studies done by Abdel-Azim et al [9] and Kavya et al[7]. The delay in seeking medical treatment may be due to asymptomatic nature of warts, but patients with palmoplantar warts in this study presented early compared to other types of warts may be due to pain.

Type of Warts:

 The most common type of wart in this present study was common warts (56.67%). This similar to observation made by Kumar et al[11]. This is in contrast to similar studies done by Verma et al [8]and Raghukumar et al[10], where palmoplantar warts were the most common type. Garde et al[4] observed that plane warts constituted the most cases in their study.

The complete response observed in present study was 66.67%. This is more when compared to studies using Candida antigen and MMR vaccine done by Majid et al[12] and Nofal et al[13], respectively. Saoji et al[14] and Garg et al[15] observed complete response was more than the present study using PPD and Mycobacterium w antigen in their studies, respectively.

The proportion of response rates were higher in patients with duration of warts less than 6 months (81.8%) and 6-12 months (81.2%) compared to duration of warts more than 12 months (33.3%). However, the differences were not statistically significant (p=0.17; NS). The response rate was higher in patients with no history of treatment in the past (84.2%) than those with history of treatment in the past present (63.6%). However, the difference was not significant statistically (p=0.40%; NS).

Time Taken for Resolution:

The minimum and maximum duration taken for the resolution of warts in this present study was 2 weeks and 8 weeks, respectively. The mean duration for resolution of warts was 5.65 weeks. The maximum number of patients in this study required 3 sessions of intralesional vitamin D3 injection. This is comparable to similar studies done by Kavya et al[7] (3 sessions, 6 weeks), Potlapati et al[5] (3 sessions, 6 weeks) and Priya et al[2] (3 sessions, 6 weeks). This is in contrast to studies done by Aktas et al[16] (1 session, 4 weeks) and Garde et al[4] (4 sessions, 8 weeks).

Complications:

In this present study, the most common complication found was swelling at site of injection in 36.67% patients. It resolved within one week after injection without any intervention. This is similar to other studies done by Verma et al [8], Kavya et al [7] and Priya et al [2]. This is in contrast to similar study done by Kumar et al [11] and Banoth [3], where they observed pain at site of injection as most common complication. The reason for this observation may be due to not administering local anaesthesia prior to injection of Vit. D3 in their studies.

Limitations:

This present study was limited by the absence of control group and by small sample size. A larger and a double-blind study is needed in future to confirm the efficacy of intralesional vitamin D3 in the treatment of warts.

Cutaneous warts were seen in all ages with majority of cases were in the 21-30 years age group (46.67%). Male predominance was noted with gender ratio of 1.72:1. The complete clearance rate of warts observed with intralesional vitamin D3 injection was 66.67%. Intralesional vitamin D3 injection is a novel treatment option for warts. It is cost- effective, safe, and has been shown to be extremely beneficial, particularly in developing countries. Unlike traditional wart therapy, this eliminates both treated and untreated warts.

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