الفهرس 
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Abstract
Genital warts caused by human papillomavirus (HPV) are one of the most common sexually transmitted infections, especially among women (Aldahan et al., 2016). Genital HPV infection has a relatively long incubation period up to 8 months. It is known to have a high recurrence rate, and the infection by certain high-risk HPV strains is known to be associated with malignancies of cervix, penis, vulva, vagina, and anus (Forman et al., 2012). Thus, factors such as long latency, lesions’ multiplicity, high recurrence rate, and the tendency to malignant transformation, are essential challenges during management of genital HPV infections.
The clinical outcome of traditional treatment modalities; such as podophyllotoxin, imiquimod, cryotherapy, electrocautery, trichloroacetic acid, photodynamic therapy, and laser, is limited to individual lesions. Therefore, they are usually inconvenient for patients with multiple and/or recurrent lesions (Bertolotti et al., 2019).
Intralesional immunotherapy was introduced to act beyond individual lesions, and to confront the previous challenges. Encouraging results are pointing to its efficacy in treating distant and hidden warts, as well as preventing recurrence. It includes the use of many therapeutic agents; such as Bacille-Calmette-Guérin vaccine, tuberculin-purified protein derivative, mumps vaccine, candida albicans antigen, mycobacterium welchii vaccine, mycobacterium indicus pranii vaccine, MMR vaccine, and trichophyton antigen (Jaisinghani et al., 2019).
As of yet, no definitive therapy has emerged as the ideal standard of care in the treatment of genital warts, that is why different modalities remain under investigation (Yanofsky et al., 2012).
Intralesional MMR vaccine; one of the best immunotherapies, has been widely used in the treatment of common warts due to its favorable results, reduced adverse effects, and lower recurrence rate. Nevertheless, literature on its efficacy in treatment of genital warts is sparse (Meena et al., 2018; Sharma et al., 2020; Gupta et al., 2020).
On the other hand, needling-induced autoinoculation is an immunotherapeutic procedure that can also stimulate the immune system, resulting in clearance of treated as well as untreated lesions. Immune-stimulation is achieved through introduction of human papilloma virus-infected keratinocytes into the subcutaneous layer. In comparison to MMR vaccine, autoinoculation does not include the injection of another antigen, and moreover, the needling technique seems to be more simple (Falknor et al., 1969; Longhurst et al., 2013; Kumari et al., 2019).
The aim of this study is to evaluate the safety and efficacy of intralesional injection of MMR vaccine in comparison with needling-induced autoinoculation in the treatment of genital warts.
Our study included 50 patients with multiple and recurrent genital warts (more than 4 genital warts) divided into two equal matched groups. One group was subjected to MMR injection and the other subjected to needling-induced autoinoculation every two weeks for maximum three sessions. Follow-up was done for 8 weeks after last session.
This study reports that both treatment options showed statistically significant value in treatment of genital warts, and here was no statistically significant difference between both study groups as regard response to treatment.
In conclusion, both MMR and needling are simple and effective modalities of immunotherapy for treatment of multiple genital warts with excellent safety profile. The only disadvantage is the long time taken for immune response to occur. Combination treatment plan can overcome this disadvantage. Needling-induced autoinoculation; being more safe and inexpensive, may be considered as a competing immunotherapeutic treatment modality for multiple and recurrent genital warts.