| |

Received: 14 August 2018    Revised: 8 October 2018    Accepted: 20 February 2019

DOI: 10.1111/jocd.13272

ORIGINAL CONTRIBUTION

Comparative clinical study of the efficacy of intralesional MMR

vaccine vs intralesional vitamin D injection in treatment of
warts

Dalia R. Shaldoum MBBCh1 | Ghada F. R. Hassan MD2  | Eman H. El Maadawy MD2 |
Gamal M. El-Maghraby MD3

1
MBBCh. Faculty of medicine, Tanta
University Abstract
2
Dermatology and Venereology, Faculty of Background: Many therapeutic modalities were reported for the treatment of warts;
medicine, Tanta University, Tanta, Egypt
however, no single treatment is completely effective.
3
Pharmaceutical Technology, Faculty of
pharmacy, Tanta University, Tanta, Egypt
Objective: To evaluate the efficacy of intralesional injection of MMR vaccine vs vita-
min D in treatment of warts.
Correspondence
Ghada Fawzy Rezk Hassan, 1 Asmaa bent
Patients and Methods: A total of 60 patients were included in the study divided
Abi-Bakr street, Neseem street, end of into two groups. Group A received intralesional MMR vaccine into largest wart, and
Moheb street, Al-Mahalla Al-Kobra, El-
Gharbia, Egypt.
group B received intralesional vitamin D3 into each lesion with maximum of five
Email: ghadafawzy53@yahoo.com warts treated in one session. A maximum of six sessions was done every 3 weeks in
both groups. Follow-up was done for 6 months for any recurrence.
Results: In group A: complete response in 80%, partial response in 6.67%, minimal
response in 6.67%, and no response in 6.67% of patients. About 60% of patients
with multiple warts showed complete clearance of distant untreated warts. In group
B: complete response in 66.7%, partial response in 6.67%, minimal response in 20%,
and no response in 6.67% of patients. There was no significant difference between
both groups. No recurrence was observed in both groups in the follow-up period.
Conclusions: Immunotherapy by both intralesional MMR vaccine and vitamin D3 is
simple, well-tolerated, effective, and cost-benefit modalities for the treatment of
warts.

KEYWORDS

MMR, treatment, vitamin D, warts

1 |  I NTRO D U C TI O N and viewed as socially unacceptable when located on visible areas
(eg, hands and face). 3
Warts are caused by infection of the epidermis with human pap- Many destructive and immunotherapeutic treatments that have
illomavirus (HPV). HPVs are divided into separate genotypes. variable success rates are available for warts. The current destruc-
Different HPV types may preferentially infect either cornified tive therapeutic options for cutaneous warts include cryotherapy,
stratified squamous epithelium of skin or uncornified mucous electrocauterization, surgical excision, laser ablation, bleomycin
membranes.1 Some warts may spontaneously disappear, while intralesional injection, topical agents, such as 5FU/salicylic acid,
others persist and can spread on other body sites. 2 Warts can be more recently, topical treatment cantharidin, podophyllotoxin, and
painful depending on their location (eg, soles and near the nails) salicylic acid.4 They have their own limitations, such as suboptimal

J Cosmet Dermatol. 2020;00:1–8. wileyonlinelibrary.com/journal/jocd© 2020 Wiley Periodicals, Inc.     1 |

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2       SHALDOUM et al.

efficacy, associated adverse effects, and high recurrence rates in ex- mepecaine 3% (ampoule of 1.8 mL). A few minutes later, 0.4 mL of
5
tensive warts. vitamin D3 (5 mg/2mL equivalent to 20 000 IU cholecalciferol) solu-
About immunotherapy, 2 various intralesional antigens that have tion was slowly injected into the base of each wart using an insulin
been used for cutaneous warts including the measles, mumps, ru- syringe. A maximum of five warts were treated per patient in one
bella (MMR) vaccine,6 skin test antigens (mumps, candida,7 tricho- session. The maximum total amount of vitamin D3 injected in one
phyton), Bacillus of Calmette and Guerin (BCG) vaccine, tuberculin, session was 5  mg. Injections were performed every 3  weeks until
and Mycobacterium w (Mw) vaccine.5 It is postulated to achieve its complete clearance or for a maximum six treatment sessions.
result by stimulating a cell-mediated immune response via recruit- In both groups A and B, the surface area and number of warts
ment of various immune cells (ie, neutrophils, lymphocytes) and re- were noted and lesions were photographed. With follow-up, the
lease of cytokines (eg, TNF-α, IL-1, IL-6, IFN-γ, GM-CSF). Though it is response to treatment and approximate decrease in size of warts
injected intralesionally, the sensitization it produces may also result was recorded and history of adverse effects was taken. Complete
in clearance of noninjected distant warts.7 So, mumps-measles-ru- response (CR) for complete disappearance of the warts and return
bella (MMR) vaccine results in regression of warts via immunomod- of normal skin markings (100%), partial response (PR) for more than
ulation and induction of immune system for destroying virus and the 50% improvement, minimal response (MR) for less than 50% im-
infected host cells.6,8 provement, and no response (NR) for stable disease (0%). Resolution
The vitamin D has multiple physiological and pharmacological of distant untreated warts was recorded. The percentage of im-
effects mediated by action of the vitamin D receptors (VDRs). VDR provement ranged from 0% to 100% according to size of regression
activators have been shown to inhibit cell replication and have im- of warts. Follow-up was done every month for six months after last
munomodulatory properties. It has been suggested that vitamin D session to detect any recurrence.
derivatives exert their effects via diverse mechanisms, including reg-
ulation of epidermal proliferation, inhibition of hyperkeratosis, and
induction of apoptosis and anti-inflammatory actions.9-12 2.1 | Statistical analysis

Data were fed to the computer and analyzed using IBM SPSS soft-
2 |  M E TH O DS ware package version 20.0 (v 16; SPSS Inc, Chicago, IL, USA).

The study was approved by the research ethics committee of the

Faculty of Medicine, Tanta University (approval code 30772/02/16). 3 | R E S U LT S
This study was done on 60 patients with single or multiple warts
(common, plantar, periungual warts) of different durations, not re- All demographic and clinical data of the patients in both groups were
ceived any treatment within 4 weeks before the injection. The par- demonstrated in Table 1 with no statistically significant difference
ticipants were collected from the Outpatient Clinics, Dermatology between both groups.
and Venerology Department, Tanta University Hospital. Exclusion As regarding the response of warts to treatment in the two
criteria were as follows: patients with other dermatological or sys- groups; Table 2 shows that the occurrence of complete response
temic diseases, having allergic response to MMR vaccine, with was higher in group A (80% of patients reached complete clearance
history of asthma or allergic skin disorders, pregnant or lactating of warts, Figures 1 and 2) than group B (66.7% of patients showed
women, patients with absolute or relative immunosuppression, and complete response, Figures 3 and 4), but there was no significant dif-
patients of chronic diseases such as chronic renal failure, hepatic in- ference between two groups. In group A, partial response was found
sufficiency, hepatitis, and cardiovascular disorders. in 2 patients, minimal response in 2 patients, and no response in 2
All participants were subjected to complete history taking, com- patients. While in group B, partial response was found in 2 patients,
plete general, and dermatological examination. Patients, who re- minimal response in 6 patients, and no response in 2 patients. As
ceived intralesional vitamin D3, were subjected to measurement of regard, the percentage of improvement of warts in the two groups
the calcium level in serum each visit. Photographs of the lesion at showed that the percentage of improvement in group A ranged from
initial presentation, at the end of the sessions, and follow-up photo- 0% to 100% with a mean of 88.33 ± 29.62. While in group B, it ranged
graphs after 6 months were obtained. from 0% to 100% with a mean of 76.33 ± 37.72. There was no signifi-
The patients were divided into group A included 30 patients who cant difference between the two groups regarding the percentage of
received intralesional MMR vaccine (VACSERA, Egypt, freeze-dried improvement (Table 2). In group A, 60% of patients (18) with multiple
0.5  mL vial). After dilution with 0.5  mL distilled water, all patients warts showed complete clearance of distant untreated warts, while
were directly injected with 0.3  mL of MMR (without presensitiza- no improvement in distant untreated warts was found in group B.
tion) into the largest wart using an insulin syringe at 3-week intervals Regarding the relation between clinical response and number of
until complete clearance or for a maximum six treatment sessions. sessions, in group A, there were two patients (6.7%) who showed
Group B also included 30 patients who received intralesional vitamin complete response after 4 sessions, 12 patients (40%) showed com-
D (MPCI.CA, Egypt). Initially, each lesion was injected with 0.1 mL of plete response after 5 sessions, and 10 patients (33.3%) showed
SHALDOUM et al. |
      3

TA B L E 1   Demographic and clinical

  Group A(MMR) Group B(Vit D) Test of Sig. P
data of both studied groups
Sex
Male 16 (53.3%) 18 (60%) Χ2 = 0.136 0.713
Female 14 (46.7%) 12 (40%)
Age (y)
≤25 10 (33.3%) 16 (53.3%) Χ2 = 1.222 0.269
>25 20 (66.7%) 14 (46.7%)
Min—Max. 9.0-45.0 14.0-34.0 t = 0.386 0.702
Mean ± SD 25.53 ± 9.96 24.33 ± 6.76
Median 27.0 25.0
Family history
Negative 16 (53.3%) 18 (60%) Χ2 = 0.136 0.713
Positive 14 (46.7%) 12 (40%)
Previous treatment
No 10 (33.3%) 14 (46.7%) 0.556 0.456
Yes 20 (66.7%) 16 (53.3%)
Number of warts
FE
Single 6(20%) 8 (26.7%) 0.186 p = 1.000
Multiple 24 (80%) 22 (73.3%)
Duration (months)
Min.-Max. 3.0-60.0 3.0-60.0 MW = 0.804 0.422
Mean ± SD 14.67 ± 14.54 13.20 ± 15.83
Median 12.0 6.0
Type
MC
Periungual 6 (20%) 6 (20%) 0.305 p = 1.000
Vulgaris 10 (33.3%) 12 (40%)
Plantar 14 (46.7%) 12 (40%)

Abbreviations: FE, Fisher exact for chi-square test; MW, P, P values for Mann-Whitney test; t, P, t
and P values for Student t test; χ2, P, χ2 and P values for chi-square.

complete response after 6 sessions. The patients who showed partial A. While dystrophy, swelling and vasovagal attack occurred only in
response reached it after 6 sessions. All other patients who showed group B. Regarding the recurrence, all cured patients in both groups
minimal or no response received 6 sessions, so there was no relation did not show any recurrence within the follow-up period which ex-
between response and increasing number of sessions. On the other tended for 6 months after the end of treatment sessions.
hand in group B, 14 patients (46.7%) showed complete response after There was a statically significant negative correlation be-
2 sessions, 4 patients (13.3%) showed complete response after 3 tween the response and the number of treatment sessions with P
sessions, and two patients (6.7%) showed complete response after 4 value = .001* in the group B only (Figure 5), and no statically sig-
sessions. The patients who showed partial response reached it after nificant correlation was found in group A. There were no significant
six sessions. There was significant relationship between number of correlations between the response and either age, sex, duration of
treatment sessions and response in group B (Table 3). There was sig- the disease, or type of warts in each group (Table 4).
nificant difference between the two groups regarding the number of
sessions, as those who received intralesional vitamin D3 needed less
number of treatment sessions to get complete response, Figure 5. 4 | D I S CU S S I O N
In group A, minimal pain occurred in 24 (80%) patients and min-
imal erythema in 30 (100%) patients. In group B, minimal pain oc- Cutaneous warts are prevalent conditions in dermatology caused
curred in 20 (66.7%) patients, minimal erythema in 12 (40%) patients, by the human papilloma virus (HPV). Treatment is almost difficult,
nail dystrophy in 2 (6.7%) patients with periungual warts, swelling and most of the modalities are destructive resulting in scarring
in 4 (13.3%) patients, and mild symptoms of vasovagal attacks in 8 and are associated with recurrences. Destructive modalities such
(26.7%) patients. No significant difference was found between the as electrical and chemical cautery are painful procedures diffi-
two groups except erythema which was significantly higher in group cult to be utilized in children.13 Intralesional immunotherapy by
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4       SHALDOUM et al.

TA B L E 2   Comparison between the

Group A Group B
studied groups according to response and
(MMR) (Vit D)
percentage of improvement
Response (n = 30) (n = 30)    
2 MC
No response 2 (6.7%) 2 (6.7%) χ p 0.889
Minimal response 2 (6.7%) 6 (20%) 1.598

Partial response 2 (6.7%) 2 (6.7%)

Complete response 24 (80.0%) 20 (66.7%)
Min.-Max. 0.0-100.0 0.0-100.0 Z = 0.906 P = 0.365
Mean ± SD. 88.33 ± 29.62 76.33 ± 37.72
Median 100.0 100.0

Note: Z and P values for Mann-Whitney test.

Abbreviations: χ2, P, χ2 and P values for chi-square; MMR, measles, mumps, and rubella; Vit D:
vitamin D.
Statistically significant at P ≤ .05.

A (I) A (II) B (I) B (II)

B (III) B (IV)
A (III) A (IV)

F I G U R E 1   B, Before treatment (group A), male patient aged 27 years old, he had verruca in multiple sites (BI, II, III, IV). T = target wart. A,
After treatment (group A), the same patient after 4 sessions with complete response of target and other distant warts

antigens like BCG, candida, trichophyton, and MMR makes the im- Na et al 8 recorded only 26.5% of complete response, 25.0% with
mune system able to produce a type 1 helper T cell (TH 1)–medi- partial response, and no response in 48.5%. Lower recorded value
ated delayed-type hypersensitivity response to various antigens, of success of treatment with MMR were also reported in Saini et
including HPV that accelerates destruction of virus and infected al13 where 6.9% showed no response, 22.84% with minimal re-
13
host cells. It can also eradicate the distant wart. Intralesional vi- sponse, 59.77% with partial response, and 26.44% with complete
tamin D3 may also affect the warts via regulating epidermal cell resolution.
10
proliferation and differentiation, inhibiting hyperkeratosis, and The mean of number of treatment sessions needed in the cur-
also through effect on different cytokines as vitamin D has im- rent study to reach complete response was 5.47 ± 0.64 sessions in
mune-regulatory actions.14 group A. But in Nofal et al15 study, the average number of treat-
In group A (MMR group), 80% showed complete response, ments to achieve complete response was 3.25 and 5.38 sessions,
6.67% had partial response, 6.67% had minimal response, and respectively. With agreement with the previous studies, in the
6.67% had no response. In Nofal et al15 study, complete response present study, there was no statistically significant relationship
occurred in 63%, partial response in 23%, and no response in 14%, between the therapeutic response to MMR vaccine and the age
which was in agreement with the present study. On the contrary, of the patients. 8,13,15
SHALDOUM et al. |
      5

(B) Also, Horn et al17 studied intralesional immunotherapy using

injection of Candida, mumps, or Trichophyton skin test antigens
efficacy in treatment for warts. There were no differences in re-
sponse among the individual antigens (Candida, 59%; mumps, 51%;
and Trichophyton, 62%; P=.48). There was no difference in response
based on sex. Also, younger age less than 40 years was positively
associated with the probability of response. The average number of
sessions in patients receiving antigen who respond was 5.8 sessions
with 57% with complete resolution of warts, 21% of whom had mul-
tiple warts showed complete clearance of all distant warts. Minimal
(A)
side effects were reported as fever, myalgias, edema, and erythema
at the injection site of acral lesions.17
Other study was done by Alikhan et al,7 where intralesional
injection of Candida antigen was used for warts treatment. It re-
vealed that 39% showed complete response, 41% with partial re-
sponse, and 20% had no response. Minimal local reactions like pain,
blistering, and swelling were reported. Patients received a mean
of 4.8 Candida antigen injections in patients showed positive re-
sponse to prior intradermal testing with antigen. Limitation in fol-
F I G U R E 2   (group A) Female patient aged 32 years old before low-up was found.7
treatment (B). Patient after 5 sessions of treatment (A) with In group B (vitamin D3 group), 66.7% of patients showed com-
complete response plete response, 6.67% had partial response, 20% had minimal re-
sponse, and 6.67% had no response. Raghukumar et al18 reported
No presensitization skin tests were done before injections complete response in 90%, partial response in 6.66%, and no re-
in the current study in agreement with Saini et al and Nofal et al sponse in 3.33%. Aktaş et al9 recorded complete clearance in 70%,
13,15 8
studies. However, in the other study of Na et al they tested 15% had a partial response, and 15% showed no response.
patients for existing immunity by intradermal injection of 0.1 mL Also, Kavya et al19 study revealed complete clearance in 78.57%,
of MMR vaccine into the volar aspect of the forearm before 14.28% had a partial response, and 7.14% showed minimal response.
treatment. So in the current study, complete response (66.7%) was also lower
The results of the current study showed complete clearance of as compared with the previous studies.9,18,19 The lower response in
other untreated warts in 18 (60%) out of 24 patients who had multi- the current study compared to the response of the other studies may
ple warts. In agreement with Nofal et al,15 who stated that complete be attributed to the differences in the study population selected for
clearance was observed in 74.5% of those presenting with distant treatment, the number of the studied patients, duration, and resis-
8
warts. However, in Na et al study, complete clearance was ob- tance of warts.9,20
served in only 24.5% of those presenting with distant warts, and in In agreement with the previous studies, in the present study,
the study done by Saini et al,13 70% of patients showed no response there was no statistically significant relationship between the
in distant warts. therapeutic response to injection of vitamin D3 and the age of the
Mechanism of intralesional injection of antigens may induce a patients.9,18,19
potent nonspecific inflammatory response toward the cells which is No improvement for the distant untreated warts was found in
infected by HPV. It has also been postulated that the trauma itself this group, as injection was done in the base of each wart alone
may lead to resolution of the wart in individuals with prior sensitiza- and with maximal five warts per session with a local anesthetic
tion. It has been postulated to be related to the release of variable agent injected before vitamin D3 injection with 3-week interval
cytokines like TNF-α, INF-γ, IL-2, IL-4, IL-5, and IL-8. In addition, it for maximum 6 sessions of treatment. Raghukumar et al18 showed
is associated with peripheral blood mononuclear cells proliferation that the sessions were 3-week interval. But in Aktaş et al, 8 the
that enhances Th1 cytokine responses resulting in activation and maximum number of sessions is only two sessions. However, in
hyperproliferation of natural killer cells and cytotoxic T cells that de- Kavya et al19 the injections were repeated at 2 weekly intervals
16
stroy cells infected by HPV. for a maximum of four injections with maximal only 2 warts per
The present study showed tolerable pain in 24 (80%) patients session.
and erythema in 30 patients (100%). No recurrence was observed The current study recorded that 46.7% of patients showing com-
during the six months of follow-up after last session in completely plete response need only two sessions. The mean of the number of
cured patients in the present study. But in studies performed by sessions in the current study was 2.93 ± 0.96 sessions, while it was
Nofal et al15 and Na et al,8 recurrence was observed in 4.8% and 3.66 and 3 in the studies done by Raghukumar et al18 and Kavya et
5.6%, respectively. al,19 respectively.
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6       SHALDOUM et al.

B (I) B (II) F I G U R E 3   (group B) Male patient

aged 32 years old before treatment (BI,
II). Patient after 3 sessions (AI, II) with
complete response of all warts

A (I) A (II)

Mechanism of action of vitamin D3 was found to have a direct ef- (B)

fect on the regulation of antimicrobial innate responses of immunity
by producing cationic antimicrobial peptides (AMPs) including the
α- and β-defensins and cathelicidins. Also, it stimulates expression of
neutrophils and monocytes. 21
Other possible suggested mechanisms of actions of vitamin D
were by induction of differentiation of epidermal keratinocytes and
apoptosis and inhibition of hyperkeratosis 10 and also serve to immu-
nomodulate different cytokines. Vitamin D inhibits differentiation T
cells. It also inhibits production of interferon-γ, IL-2, and IL-6 which
(A)
are potent mediators of the inflammatory response. Besides, vitamin
D promotes suppressor T-cell activity and inhibits cytotoxic and nat-
ural killer cell formation.14
The present study showed that tolerable pain occurred in 20
patients (66.7%), erythema in 12 patients (40%), nail dystrophy
2 patients (6.7%) with periungual warts, swelling in 4 patients
(13.3%), and mild symptoms of vasovagal attacks in 8 patients
(26.7%).
Raghukumar et al18 showed the same side effects except for nail
dystrophy where mild-to-moderate pain developed in 100%, edema
F I G U R E 4   (group B) Male patient aged 17 years old before
in 3.33%, and mild erythema in 5%. Unlike Aktaş et al9 reported treatment (B). Patient after 2 sessions (A) with complete response
that none of the patients experienced adverse effects, and the only of all warts
patient complaints were of minimal to moderate pain during injec-
tion. But in Kavya et al19 study, all side effects were minor with no The present study showed no recurrence was observed during
life-threatening complications, and swelling was reported in 78.57% the six months of follow-up after last session in completely cured pa-
and also depigmentation in one patient. tients. Aktaş et al9 found the same findings. However, in the studies
SHALDOUM et al. |
      7

TA B L E 3   Comparison between the

Group A Group B
studied groups according to number of
Number of (MMR) (Vit D)
sessions
sessions (n = 30) (n = 30) Test of Sig. P
2 MC
2 0 (0.0%) 14 (46.7%) χ  = 26.966* p < .001*
3 0 (0.0%) 4 (13.3%)
4 2 (6.7%) 2 (6.7%)
5 12 (40%) 0 (0.0%)
6 16 (53.3%) 10 (33.3%)
Min.—Max. 4.0-6.0 2.0-6.0 T = 8.497* <.001*
Mean ± SD. 5.47 ± 0.64 2.93 ± 0.96
Median 6.0 4.0

Abbreviations: χ2, P: χ2 and P values for chi-square test; MC, Monte Carlo for chi-square test; t, P, t
and P values for Student t test; MMR, measles, mumps, and rubella; Vit D, vitamin D.
*Statistically significant at P ≤ .05

TA B L E 4   Correlation between percentage of improvement with

different parameters in each group

Percentage of improvement

Group A (MMR) Group B (Vit D)

  rs P rs P

Age (years) −.035 .903 −.046 .871

Sex (Female) .177 .528 .263 .344
Duration (months) −.410 .129 −.327 .234
Number of sessions −.453 .090 −.786* .001*
Type
Periungual .248 .372 −.460 .085
Vulgaris −.304 .270 .263 .344
Plantar .088 .754 .113 .689

Note: Abbreviations: MMR: measles, mumps, and rubella; r: Pearson

coefficient; Vit D: vitamin D.
*Statistically significant at P ≤ .05.

F I G U R E 5   Correlation between percentages of improvement to disappearance of the wart within three months, without pain or
with number of sessions in group B
other side effects and no recurrence within the 9 months since its
disappearance.
done by Raghukumar et al18 and Kavya et al19 recurrence was ob- According to our best knowledge, the current study is the first
served in 3.33% and in one patient, respectively. study to compare MMR vaccine and vitamin D3 intralesional injec-
Other study was done by Imagawa and Suzuki,11 where vitamin tions as therapeutic options for warts, and from the results, we can
D3 derivatives were used topically in treatment of warts in which conclude that: MMR vaccine and vitamin D3 intralesional injections
local application of (maxacalcitol ointment 25 μg/g) three times a are simple, effective, safe, office technique, well-tolerated, and
day was advised. In some cases, the subjects were advised to apply cost-efficient modalities in the treatment of different types of warts
gauze smeared with approximately a 1 mm thickness of the oint- even if recalcitrant or multiple. It is easy to administer in outpatient
ment after a bath and leave it on until they bathed the next day. clinics.
In all patients, the warts successfully disappeared within 2 weeks MMR vaccine needed more sessions of treatment to show com-
to 6 months of the start of treatment without pain or other side plete clearance of warts, and clearance of distant untreated warts
effects. was reported, while vitamin D3 needed less number of session treat-
10
Another case report done by Moscarelli et al showed that ments to show complete clearance of warts and no clearance of
local application of activated vitamin D (gauze wet with calcitriol distant untreated warts were found. Both modalities of treatments
0.5 μg solution) at least two times a day and the advice to reapply showed a decreased risk of recurrence which is a big problem that
a gauze wet with calcitriol 0.5 solution after each hand washing led faces both the patients and the dermatologists.
 |
8       SHALDOUM et al.

C O N FL I C T O F I N T E R E S T 12. Liu PT, Stenger S, Li H, et al. Toll-like receptor triggering of a vi-

tamin D-mediated human antimicrobial response. Science.
The authors declared that there were no conflicts of interest and no
2006;311:1770-1773.
financial support of this work. 13. Saini S, Dogra N, Dogra D. A prospective randomized open label
comparative study of efficacy and safety of intralesional mea-
ORCID sles, mumps, rubella vaccine versus 100% trichloroacetic acid
Ghada F. R. Hassan  https://orcid.org/0000-0001-9131-0263 application in the treatment of common warts. Int J Res Med Sc.
2016;4(5):1529-1533.
14. Shahriari M, Kerr PE, Slade K, et al. Vitamin D and the skin. Clin
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