ORIGINAL RESEARCH
Intralesional Immunotherapy with
ABSTRACT
INTRODUCTION: Anogenital warts (AGWs) are one
of the leading sexually transmitted infections in the
world. This condition poses a number of challenges
to dermatologists, including the reluctance of
patients to consult a physician and the high
likelihood of relapse. Individuals with AGWs suffer
a substantial psychological morbidity. Intralesional
immunotherapy with the measles, mumps, and
rubella (MMR) vaccine has been reported to be an
effective treatment for warts. However, literature
on the efficacy of intralesional immunotherapy
with the MMR vaccine for the treatment of
anogenital warts is sparse. OBJECTIVE: We sought
to determine the efficacy of the MMR vaccine for
the treatment of anogenital warts at an outpatient
dermatology department in Government Medical
College Haldwani in India. METHODS: This was a
hospital-based, longitudinal study the included 35
patients. In patients with genital warts, 0.5mL of
the MMR vaccine after reconstitution with distilled
water was injected intradermally into their single
largest wart. Injections were given every three
weeks until a maximum of three injections was
achieved. Pre- and posttreatment photographs
were assessed to compare the degree of reduction
in the size and number of warts. The therapeutic
response was evaluated as follows: No response
(<50% reduction in the number of warts), Relative
response (50%–99% reduction), complete
response (100% reduction). RESULTS: On average,
a 42.4-percent response was observed in the first
three weeks after administering the MMR vaccine,
which increased to 75.8 percent after the second
vaccine at six weeks and nearly 98 percent after
the last vaccine at nine weeks. CONCLUSION: Our
results suggest that intralesional immunotherapy
with the MMR vaccine can serve as a safe and
effective therapy for the treatment of AGWs.
KEYWORDS: MMR vaccine, anogenital warts,
immunotherapy
JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY August 2020 • Volume 13 • Number 8
40
Measles Mumps Rubella Vaccine for
the Treatment of Anogenital Warts:
An Open-label Study
by SHILPI SHARMA, MD, and SAURABH AGARWAL, MD
Dr. Sharma is Assistant Professor in the Department of Dermatology, Venereology, and Leprology at the Government
Medical College Haldwani in Uttarakhand, India. Dr. Agarwal is Professor and Unit Head of the Department of Dermatology,
Venereology, and Leprology at the Government Medical College Haldwani in Uttarakhand, India.
J Clin Aesthet Dermatol. 2020;13(8):40–44
P
Warts are common viral infections caused by
more than 120 papillomaviruses. Of these, over
40 can cause the anogenital tract infections
leading to external anogenital warts (AGWs)
and anogenital cancers.1 Anogenital warts
are one of the leading sexually transmitted
infections in the world.2 This condition poses
a number of challenges to dermatologists,
including the reluctance of patients to consult
a physician and the high likelihood of relapse.
Individuals with AGWs can suffer from
substantial negative psychological impacts.
Treatment with lower side effects and low
recurrence rate is desirable. Various treatment
modalities are available for warts, including
topical therapies, such as trichloroacetic
acid, salicylic acid, podophyllotoxin, and
5-fluorouracil, radiocautery, cryotherapy,
surgical excision, carbon dioxide laser, and
immunotherapy.3
Recently, immunotherapy has gained
popularity as an effective treatment for warts.
Antigens, such as the measles, mumps, and
rubella (MMR) vaccine, Mycobacterium w
vaccine (MWV) Candida albicans and Bacillus
Calmette-Guérin (BCG), have been used
intralesionally for the treatment of warts,
with variable responses.3 While intralesional
immunotherapy with the MMR vaccine has been
FUNDING: No funding was provided for this study.
DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article.
CORRESPONDENCE: Shilpi Sharma, MD; Email: shilssss87@gmail.com
reported as an effective treatment for warts, the
exact mechanism of action in the clearance of
warts is not known.4 It seems to use the immune
system’s capacity to mount a Type 1 helper T cell
(TH1) mediated delayed-type hypersensitivity
response to various antigens, including human
papillomavirus (HPV).4 However, literature on
the efficacy of intralesional immunotherapy
with the MMR vaccine for the treatment of
anogenital warts is sparse. We evaluated the
efficacy of the MMR vaccine for the treatment of
anogenital warts at an outpatient dermatology
department at Government Medical College
Haldwani in India.
METHODS
This was a hospital-based, longitudinal study
of 35 patients conducted in the Department
of Dermatology, Venereology, and Leprosy
at Government Medical College Haldwani in
India following clearance from the Institutional
Review Board.
Inclusion and exclusion criteria.
Patients with genital warts who presented to
our clinic from September 2018 to May 2019
and who were not using anti-wart treatment
within the previous month were included in
the study after providing informed consent.
Exclusion criteria included prior hypersensitivity
 ORIGINAL RESEARCH

A A B

FIGURE 2. A case of complete clearance of genital warts: A) before treatment; B) complete clearance after third injection
B
TABLE 1. Descriptive statistics of the quantitative variables
PATIENT STANDARD
RANGE MINIMUM MAXIMUM MEAN
CHARACTERISTICS (N=33) DEVIATION
Age (years) 31.00 17.00 48.00 23.9697 7.64642
Duration of Disease 15.00 1.00 16.00 6.1818 3.91675
Number of Lesions 37.00 3.00 40.00 17.5455 11.87721

TABLE 2. Sex and marital status distribution

SEX UNMARRIED MARRIED TOTAL
N 15 9 24
Male Percent within sex 62.5% 37.5% 100.0%
Percent within marital status 71.4% 75.0% 72.7%
C N 6 3 9
Female Percent within sex 66.7% 33.3% 100.0%
Percent within marital status 28.6% 25.0% 27.3%
N 21 12 33
Total % within Sex 63.6% 36.4% 100.0%
% within Marital Status 100.0% 100.0% 100.0%

FIGURE 1. A case of complete clearance of genital
warts; A) before treatment; B) after second injection; and
C) complete clearance after the third injection
reaction to MMR antigen, pregnancy, lactation,
presence of any active infections (e.g., herpes),
tuberculosis, and immunosuppression (e.g.,
human immunodeficiency virus, patients taking
immunosuppressives).
Baseline evaluation. Thirty-five patients
met inclusion criteria and were recruited into
the study. Written informed consent and
detailed demographic and historical clinical data
were obtained and recorded for each patient.
Photographic documentation was performed for
each patient.
Dosage and administration. The MMR
vaccine (TRESIVAC®; Serum Institute of India
Pvt. Ltd., Pune, India) used was a freeze-
dried preparation of live attenuated strains of
measles, mumps, and rubella viruses available
in a single-dose vial of 0.5mL. In patients with
genital warts , 0.5mL of the MMR vaccine
after reconstitution with distilled water was
injected intradermally into their single largest
wart. Injections were administered every three
weeks until a maximum of three injections was
achieved.
Assessment methods. Pre- and post-
intervention photographs were assessed to
compare the degree of reduction in the size
and number of warts. The therapeutic response
was evaluated as follows: no response (<50%
reduction in the number of warts), relative
response (50%–99% reduction), and complete
response (100% reduction). Adverse events,
such as pain, swelling, and flu-like symptoms
were noted following injection.
Statistical analysis. All the results have
been generated using SPSS software v 22.0
and Microsoft Excel postanalysis on the clinical
data. Independent t-tests and chi-square tests
have been applied for analysis between various
attributes at 95% confidence level.
RESULTS
A total of 35 patients were included in the
study. Of these, two patients did not complete
the study or were lost to follow up, so they
were excluded from further analysis. Hence,
the total number of patients in the sample size
was 33. The mean age of study participants was
24.0±7.6 years. All the patients had multiple
lesions, ranging from 3 to 40, with the average
number of lesions being 18. The maximum
duration of disease among the patients was 16

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 ORIGINAL RESEARCH

weeks, with an average duration of 6.2±3.9

A B
weeks (Table 1). Regarding sex distribution,
72.7 percent of the patients were men and 27.3
percent of the patients were women (Table 2).
On the first visit, an average of 18 lesions
were observed, which decreased to 10 lesions
after administration of the first MMR vaccine,
five lesions after the second injection, and
one lesion after the third injection. In the
patients who showed complete response,
around 14 lesions were observed on average,
which decreased to six lesions after the first
FIGURE 3. A case of relative response in genital warts; A) before treatment; and B) after third injection MMR vaccine and to three lesions after the
second injection of MMR vaccines. However,
in the patients who showed relative response,
A B 24 lesions were observed on average, which
decreased to 16 lesions after the first MMR
vaccine, seven lesions after the second
injections, and one lesion after the third (Table
3).
After three weeks of administering the
first MMR vaccine, an average 42.4-percent
improvement was seen in the 33 patients. After
the second vaccine, the response in the patients
was 75.8 percent. After the last vaccine, the
average response was near 98 percent in all
the patients. In the patients who saw complete
FIGURE 4. A case of relative response in genital warts; A) before treatment; and B) after third injection
clearance of their genital warts, a 48.7-percent
response to the first vaccine and 74.6-percent
TABLE 3. (Overall and group-wise) Mean number of lesions in patients after 3, 6 and 9 weeks
to the second vaccine was observed (Figures 1
NUMBER OF NUMBER OF NUMBER OF
NUMBER OF and 2). However, in the patients who showed
THERAPEUTIC RESPONSE LESIONS AFTER 3 LESIONS AFTER 6 LESIONS AFTER 9
LESIONS
WEEKS WEEKS WEEKS
a relative response, a 31.3-percent response to
the first vaccine, a 77.9-percent to the second
Relative Mean 24.0000 16.2500 6.7500 1.2500
Response
vaccine, and a 93.2-percent response to the
N 12 12 12 12
third MMR vaccine was observed (Table 4)
Complete Mean 13.8571 5.7143 3.0000 0.0000
(Figures 3 and 4).
Response N 21 21 18 15 The average duration of disease in the
Mean 17.5455 9.5455 4.5000 0.5556 patients who showed complete response
Total
N 33 33 30 27 was 4.7±2.6 weeks and that in the patients
who showed relative response to the MMR
TABLE 4. (Overall and group-wise) Mean percentage response in patients after 3, 6 and 9 weeks
vaccine was 8.8±4.6 weeks. Thus, the
PERCENTAGE RESPONSE PERCENTAGE RESPONSE PERCENTAGE RESPONSE duration of disease in the patients who saw
THERAPEUTIC RESPONSE
AFTER 3 WEEKS AFTER 6 WEEKS AFTER 9 WEEKS
complete clearance of their genital warts was
Relative Mean 31.2500 77.9150 93.1250
comparatively smaller (Table 5). P-value after
Response N 12 12 12 Levene’s tests was 0.045, less than 0.05, and
Complete Mean 48.7414 74.6257 100.0000 the p-value for the t-test was 0.014, less than
Response N 21 21 21 0.05; thus, there was a significant difference in
Total
Mean 42.3809 75.8218 97.5000 the duration of disease in the patients from two
N 33 33 33 different response groups (Table 6).
Adverse effects were evaluated at every
TABLE 5. Relationship between duration of disease and response to the vaccine (group statistics) visit, and the only adverse event reported was
THERAPEUTIC RESPONSE N MEAN STANDARD DEVIATION STANDARD ERROR MEAN swelling following injection, which was seen in
Relative Response 12 8.7500 4.63436 1.33782 18.2 percent of patients (Table 7).
Complete Response 21 4.7143 2.55231 0.55696

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 ORIGINAL RESEARCH
TABLE 6. Relationship between duration of disease and response to the vaccine (independent samples test)
LEVENE’S TEST FOR EQUALITY OF
VARIANCES
DURATION OF
DISEASE
F SIG.
Equal variances
4.377 0.045
assumed
Equal variances
NA NA
not assumed
DISCUSSION
Intralesional immunotherapy has recently
gained popularity in the treatment of warts.
It utilizes the ability of the immune system
to mount a delayed type hypersensitivity
response to various antigens or wart tissue
leading to production of Th1 cytokines which
stimulate cytotoxic T cells and natural killer
cells to eradicate HPV infection. This stimulated
immune response has a potential to resolve the
distant warts as well and not the wart alone
that has been primarily injected.4
Intralesional immunotherapeutic agents
used for the treatment of genital and
extragenital include Mw vaccine, BCG vaccine,
the MMR vaccine, Candidial extract, and
Trichophyton antigen.5 Immunotherapy using
the MMR vaccine has been widely used for the
treatment of cutaneous warts due to favorable
results with reduced adverse effects and lower
recurrence rates.6 We could not find any study in
the literature where the MMR vaccine had been
used specifically for the treatment of genital
warts; however, studies reporting on the use of
intralesional mumps antigen for genital warts
are available.7
In our study, a 42.4-percent response was
seen in the 33 patients, on average, after three
weeks of administering the first MMR vaccine.
After the second vaccine, the response in the
patients was 75.8 percent. After the last vaccine,
the average response was near 98 percent in
all patients. In the patients who saw complete
clearance of their warts, a 48.7-percent
response to the first vaccine and 74.6-percent
to the second vaccine was observed. However,
in the patients who showed relative response,
a 31.3-percent response to the first vaccine,
77.9-percent response to the second vaccine,
and 93.2-percent response to the third MMR
vaccine was observed.
In our study, we observed the average
duration of disease in the patients who showed
T-TEST FOR EQUALITY OF MEANS
MEAN
t df SIG. (2-TAILED)
DIFFERENCE
3.243 31 0.003 4.03571
2.785 14.897 0.014 4.03571
TABLE 7. Adverse events
ADVERSE EVENTS FREQUENCY
No symptoms 27
Swelling 6 18.2
Total 33
complete response to be 4.7±2.6 weeks.
Patients who showed relative response to the
MMR vaccine had an average disease duration
of 8.8±4.6 weeks; thus, the disease duration
of the patients who saw complete clearance of
their condition was comparatively smaller. The
p-value according to Levene’s tests was 0.045
and t-test was 0.014 at 95% confidence level.
Thus, there was a significant difference in the
duration of disease in the patients from two
different response groups. The mean duration
of disease is smaller with low variability in the
patients who showed complete response to the
vaccine. Thus, patients with a shorter duration
of disease showed a relatively better response
to the MMR vaccine, and such patients have a
higher chance of seeing complete clearance of
their warts.
Many studies have demonstrated the
effectiveness of the MMR vaccine in the
treatment of extragenital warts. A study by
Mohamad et al8 evaluated the effects of the
MMR vaccine in the treatment of plantar warts
in 100 patients. The investigator observed a
significantly higher rate of complete clearance
compared to the control group (82% vs. 0%,
respectively). The rate of partial response was
six percent versus 30 percent, and the rate of
no response was 12 percent versus 70 percent,
respectively.
A study by Nofal et al9 also studied the
effects of the MMR vaccine in 135 patients with
single or multiple recalcitrant or nonrecalcitrant
common warts. The investigators observed
complete response in 57 patients (81.4%),
partial response in seven patients (10%), and
JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY August 2020 • Volume 13 • Number 8
95% CONFIDENCE INTERVAL OF THE
STD. ERROR
DIFFERENCE
DIFFERENCE
LOWER UPPER
1.24433 1.49790 6.57353
1.44913 0.94511 7.12632
PERCENT VALID PERCENT CUMULATIVE PERCENT
81.8 81.8 81.8
18.2 100.0
100.0 100.0 NA
no response in six patients (8.6%) of the MMR
group.
Previous studies have evaluated the MMR
vaccine for the treatment of cutaneous warts,
including Zamanian et al,10 who observed a
75-percent response to MMR injections; Gamil
et al,11 who reported an 87-percent complete
response; Dhope et al,12 who observed a
complete response in 65 percent of patients;
Raju et al,13 who observed complete remission
in 70.4 percent of patients; and Naseem et
al,14 who observed a complete response in 81
percent of patients. However, none of these
studies evaluated the efficacy of the MMR
vaccine for AGWs specifically.
Our study demonstrates the therapeutic
potential of the MMR vaccine in treatment
of genital warts. Similar to our study, many
studies have demonstrated the efficacy of other
intralesional immunotherapeutic agents on
AGWs. A study by King et al7 retrospectively
studied the efficacy of immunotherapy with
mumps, Candida, and/or Trichophyton skin test
antigens in patients with AGWs and reported
complete resolution in 5 of 10 patients who
completed the therapy. In a pilot study of
intralesional injection of Mw vaccine, 8 of
10 patients with AGWs showed complete
resolution.15 Eassa et al16 reported complete
clearance in nearly half of the pregnant women
with AGWs who received intralesional purified
protein derivative of Mycobacterium tuberculosis.
In our study, the only adverse event reported
was swelling following injection, which was
seen in 18.2 percent of patients, while in other
studies where MMR vaccine has been used for
43
 ORIGINAL RESEARCH
the treatment of extragenital warts, pain during
injection and flu-like symptoms were commonly
reported side effects.10,17,18
Limitations. Limitations to this study
include small sample size and the short duration
of follow-up period. Further randomized,
double-blinded, and vehicle-controlled studies
with larger sample sizes, are required to support
our findings.
CONCLUSION
Our results suggest that intralesional
immunotherapy with the MMR vaccine can
serve as an effective therapy for the treatment
of anogenital warts. To our knowledge, this
is the first study where the MMR vaccine is
used for the treatment of anogenital warts,
as previous studies have been limited to the
evaluation of the MMR vaccine for the treatment
of extragenital warts. Larger, prospective,
randomized, controlled trials are needed to
confirm our results.
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