Conditions: Warts
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 77
Healthy volunteers: no

Brief summary:
Researchers are trying to find out if injecting Vitamin D into a wart is an effective treatment.

Detailed description:

Arms:
arm 1: Subjects will receive a Vitamin D3 injection into their wart arm 2: Subjects will receive a placebo injection into their wart

Interventions: intervention 1: Vitamin D3 intervention 2: Placebo
Intervention descriptions: intervention 1: Intralesional injection of 0.3 ml 40,000 IU/ml vitamin D3 into one wart intervention 2: 0.3 ml injection of sterilized sesame oil with no active study ingredient

Protocol document:
Prot_SAP_000.pdf: 
 
Efficacy of Intralesional Vitamin 
D Injection for Treatment of 
Common Warts: A Randomized 
Controlled Trial 
 
NCT# 04278573 
December 14, 2020 


Vitamin D injection for Treatment of Common Warts 
 
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EFFICACY OF INTRALESIONAL VITAMIN D INJECTION FOR 
TREATMENT OF COMMON WARTS: A RANDOMIZED 
CONTROLLED TRIAL 
 
 
 
Regulatory Sponsor: 
Dr. Stephen P. Merry 
Department of Family Medicine 
Mayo Clinic 200 First Street SW, Rochester, MN 55905 
507-284-5180 
 
Study Product: 
Cholecalciferol (Vitamin D3) 
Protocol Number: (IRBe) 
19-010219 
IND Number: 
146953 
 
 
 
 
 
Initial version: 12/14/2020 Version (7.0)  
 
 


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Table of Contents 
 
STUDY SUMMARY ...................................................................................................................................... 5 
1 
INTRODUCTION ................................................................................................................................. 6 
1.1 
BACKGROUND .................................................................................................................................... 6 
1.2 
INVESTIGATIONAL AGENT .................................................................................................................... 6 
1.3 
CLINICAL DATA TO DATE..................................................................................................................... 7 
1.4 
DOSE RATIONALE................................................................................................................................ 9 
1.5 
RISKS AND BENEFITS ......................................................................................................................... 10 
2 
STUDY OBJECTIVES ........................................................................................................................ 10 
3 
STUDY DESIGN ................................................................................................................................. 10 
3.1 
GENERAL DESCRIPTION ..................................................................................................................... 11 
3.2 
NUMBER OF SUBJECTS ....................................................................................................................... 11 
3.3 
DURATION OF PARTICIPATION ............................................................................................................ 11 
3.4 
PRIMARY STUDY ENDPOINTS .............................................................................................................. 11 
3.5 
SECONDARY STUDY ENDPOINTS ......................................................................................................... 11 
3.6 
IDENTIFICATION OF SOURCE DATA ...................................................................................................... 12 
4 
SUBJECT SELECTION ENROLLMENT AND WITHDRAWAL ...................................................... 12 
4.1 
INCLUSION CRITERIA ......................................................................................................................... 12 
4.2 
EXCLUSION CRITERIA ........................................................................................................................ 12 
4.3 
SUBJECT RECRUITMENT, ENROLLMENT AND SCREENING ....................................................................... 12 
4.4 
EARLY WITHDRAWAL OF SUBJECTS .................................................................................................... 13 
4.4.1 
When and How to Withdraw Subjects ........................................................................................ 13 
4.4.2 
Data Collection and Follow-up for Withdrawn Subjects .............................................................. 14 
5 
STUDY DRUG .................................................................................................................................... 14 
5.1 
DESCRIPTION .................................................................................................................................... 14 
5.2 
TREATMENT REGIMEN ....................................................................................................................... 14 
5.3 
METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS ................................................................ 14 
5.4 
PREPARATION AND ADMINISTRATION OF STUDY DRUG ......................................................................... 14 
5.5 
SUBJECT COMPLIANCE MONITORING ................................................................................................... 15 
5.6 
PRIOR AND CONCOMITANT THERAPY .................................................................................................. 15 
5.7 
PACKAGING ...................................................................................................................................... 15 
5.8 
MASKING/BLINDING OF STUDY........................................................................................................... 15 
5.9 
RECEIVING, STORAGE, DISPENSING AND RETURN ................................................................................. 15 
5.9.1 
Receipt of Drug Supplies .......................................................................................................... 15 
5.9.2 
Storage ................................................................................................................................... 16 
5.9.3 
Dispensing of Study Drug ......................................................................................................... 16 
5.9.4 
Return or Destruction of Study Drug ......................................................................................... 16 
6 
STUDY PROCEDURES ...................................................................................................................... 17 
6.1 
SCREENING VISIT. ............................................................................................................................. 17 
6.2 
BASELINE VISIT. ............................................................................................................................... 17 
6.3 
AS NEEDED INJECTION VISITS. ............................................................................................................ 17 
6.4 
POST INJECTION FOLLOW-UP VISIT ..................................................................................................... 17 
7 
STATISTICAL PLAN ......................................................................................................................... 18 
7.1 
SAMPLE SIZE DETERMINATION ........................................................................................................... 18 
7.2 
STATISTICAL METHODS ..................................................................................................................... 19 
7.3 
SUBJECT POPULATION(S) FOR ANALYSIS ............................................................................................. 20 


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8 
SAFETY AND ADVERSE EVENTS ................................................................................................... 20 
8.1 
DEFINITIONS ..................................................................................................................................... 20 
8.2 
RECORDING OF ADVERSE EVENTS ....................................................................................................... 22 
8.3 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS .......................................... 22 
8.3.1 
Sponsor-Investigator reporting: notifying the Mayo IRB ............................................................. 22 
8.3.2 
Sponsor-Investigator reporting: Notifying the FDA ..................................................................... 22 
8.4 
UNMASKING/UNBLINDING PROCEDURES ............................................................................................. 23 
8.5 
MEDICAL MONITORING ..................................................................................................................... 23 
9 
DATA HANDLING AND RECORD KEEPING .................................................................................. 24 
9.1 
CONFIDENTIALITY ............................................................................................................................. 24 
9.2 
SOURCE DOCUMENTS ........................................................................................................................ 24 
9.3 
CASE REPORT FORMS ........................................................................................................................ 24 
9.4 
RECORDS RETENTION ........................................................................................................................ 25 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ................................................................ 26 
10.1 
STUDY MONITORING PLAN ............................................................................................................ 26 
10.2 
AUDITING AND INSPECTING ........................................................................................................... 26 
11 
ETHICAL CONSIDERATIONS ......................................................................................................... 26 
12 
STUDY FINANCES ............................................................................................................................ 26 
12.1 
FUNDING SOURCE ......................................................................................................................... 26 
12.2 
SUBJECT STIPENDS OR PAYMENTS .................................................................................................. 26 
13 
PUBLICATION PLAN ....................................................................................................................... 27 
14 
REFERENCES ................................................................................................................................... 27 
 
 
 
 
 
 
 
 
 
 


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LIST OF ABBREVIATIONS 
AE 
Adverse Event/Adverse Experience 
CFR 
Code of Federal Regulations 
Co-I 
Co-Investigator 
CRF 
Case Report Form 
ECH 
Employee and Community Health 
ED 
Emergency Department 
HER 
Electronic Health Record 
EMR 
Electronic Medical Record 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
IU 
International Unit 
Non-UPIRTSO 
Non-Unanticipated Problem Involving Risk to Subjects or Others 
PHI 
Protected Health Information 
PI 
Principal Investigator 
SAE 
Serious Adverse Event/Serious Adverse Experience 
UPIRTSO 
Unanticipated Problem Involving Risk to Subjects or Others 
 
 
 
 
 


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Study Summary 
Title 
Efficacy of Intralesional Vitamin D injection for Treatment of Common 
Warts: A Randomized Controlled Trial 
Running Title 
Vitamin D injection for Treatment of Common Warts 
Protocol Number 
19-010219 
Phase 
Clinical study phase II 
Methodology 
Double blind; Randomized, placebo – controlled design 
Overall Study 
Duration 
The study will run until the n is reached with target based on sample 
size calculation.  
Subject Participation 
Duration 
Maximum of 168 days 
Single or Multi-Site  
Single 
Objectives 
In this study, we aim to explore the efficacy of intralesional vitamin D 
injection into cutaneous warts by comparing the rates of wart 
improvement and resolution between a population randomly selected to 
receive either blinded Vitamin D wart injections or placebo. 
Number of Subjects 
80 (40 intervention, 40 control) 
Diagnosis and Main 
Inclusion Criteria 
Adult ECH patients seen at the Mayo Clinic Rochester practices 
suffering from one or more cutaneous warts.. Both recalcitrant and non-
recalcitrant warts will be included. 
Study Product, Dose, 
Route, Regimen 
Cholecalciferol (Vitamin D3), injection of 0.3 ml 40,000IU, 
intralesional (specifically at the base of the wart with needle centered 
under the wart) at baseline visit and weeks 4 and 8 as needed. 
Duration of 
Administration 
56 days  
Reference therapy 
Placebo 
Statistical 
Methodology 
Primary Endpoint: 
Complete regression of index wart. 
Secondary Endpoints:  
Partial regression of index wart as measured in percent surface area lost. 
Complete or partial regression of up to 7 other warts followed. 
 
 
 


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1 Introduction 
 
This document is a protocol for a human research study. This study will be carried out in 
accordance with the applicable United States government regulations and Mayo Clinic research 
policies and procedures.  
1.1 
Background 
 
Warts are very common benign proliferations of epidermal cells. Warts are typically treated by 
traditional destructive modalities, such as cryotherapy, topical salicylic acids, candida antigen 
immunotherapy, and even laser surgery. All of these treatment modalities can be painful and 
expensive, and disappointingly, many warts are refractory to treatment and require multiple 
treatment sessions1,3.  
 
Topical Vitamin D3 has been used for wart treatment with success14-17. Although the 
pathophysiology of Vitamin D on warts is not completely clear, it is speculated that Vitamin D 
may regular cell proliferation and can modulate cytokine production affecting innate immunity 
and has an important role as immunomodulator13. Recent case reports and case series of 
intralesional Vitamin D3 have shown promise as well, but these studies are limited18-23.  
 
Our study will seek to determine whether an injectable low-dose form of vitamin D is efficacious 
in treatment of cutaneous warts. Our randomized, double-blind, placebo-controlled methodology 
will provide level A evidence of efficacy. If efficacious, this would represent a translational 
science opportunity for production of an injectable vitamin D3 product for intradermal injection 
for cutaneous warts.   
 
The population to be studied will include adults ≥ 18 years old seen at the Mayo Clinic 
Rochester practices suffering from one or more cutaneous warts as diagnosed by the examining 
physician at baseline visit based on typical diagnostic characteristics and able to provide consent. 
Both recalcitrant and non-recalcitrant warts will be included. 
1.2 
Investigational Agent 
 
Vitamin D is a fat-soluble vitamin that is produced endogenously when ultraviolet rays from sun 
exposure trigger vitamin D synthesis. Vitamin D is also naturally present in foods and is widely 
available as a dietary supplement.  
 
An article in Science in 2006 discussed the effects of activated vitamin D receptors as 
immunomodulatory and inhibiting cell replication. Activation of toll-like receptors on 
macrophages induce an antimicrobial peptide through an increase in vitamin D receptors and 
vitamin D-hydroxylase genes, properties of vitamin D that may explain its potential mechanism 
of action as an immune modulator, which may represent an efficacious and low cost treatment 
for the common wart.13  
 


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Vitamin D3 will be supplied as cholecalciferol 40,000 IU/mL by Mayo Production Lab.  40,000 
IU/ml is the formulation that Mayo Clinic has been mixing for administration as treatment for 
hypovitaminosis D.  This drug product will be dispensed through the research pharmacy in 1.5 
mL vials containing 0.3 mL of the drug product prepared in sesame oil.   
1.3 
Clinical Data to Date 
 
Cutaneous warts are a common dermatologic affliction caused by human papillomaviruses 
(HPVs) which affect the epithelium of skin.  Cutaneous warts include common, plantar and flat 
warts.  Diagnosis of a wart is usually straightforward, based on typical epidermal thickening and 
keratinization that developed over weeks to months and visible capillaries in the base.1   
Spontaneous remission occurs in the majority of cases of cutaneous warts in children within 1-2 
years but may take several years in adults particularly among those without intact cellular 
immunity. A 2006 Cochrane review of 21 randomized clinical trials of topical treatments for 
warts found an average wart regression rate for placebo of 27% over an average of 15 weeks.2  
Up to a third of cases do not resolve but become recalcitrant to destructive therapies.1,3  
 
Standard therapy for warts begins with over-the-counter products that produce physical 
destruction of the lesion including topical salicylic acid (SA) and low-potency cryotherapy.  
Studies done have been mostly of poor methodologic quality, and widely heterogeneous (varying 
strengths and formulations of SA, paring down of wart prior to treatment or not, varying 
locations of warts, widely varying cryotherapy durations of a few seconds to 30 seconds of one 
or more freeze cycles).  SA appears to be about 1.6 times more likely to clear warts than placebo 
(meta-analysis of 5 studies of 333 patients) and has demonstrated mean cure rates of 49% vs 
23% for placebo (pooled analysis of 16 studies with 813 patients with variable durations up to 18 
months).4  In one 13 week randomized trial of SA 40% ointment (for comparison, Compound W 
in the US is 17% liquid) vs cryotherapy by cotton-tipped applicator dipped in liquid nitrogen vs 
placebo, cure rates for all sites were 15% vs 46% vs 7% with lower efficacy of cryotherapy for 
plantar warts (30% vs 33% with SA ointment). A 23% rate of spontaneous resolution of warts 
(placebo arm) was noted  in that 13 week trial.5,6 Treatment guidelines from both specialty 
(British Association of Dermatologists) and generalist physician groups (American Academy of 
Family Physicians) recommend SA and/or cryotherapy as first line treatment.1,7 
 
Patients presenting to their primary care provider for treatment of warts usually receive in-office 
cryosurgery with or without paring or curettage.  In cases where warts are recalcitrant to first or 
second-line therapies, immunotherapy (e.g. Candida antigen at Mayo Clinic and elsewhere also 
MMR, BCG or PPD), and topical or intralesional 5-fluorouracil or bleomycin, electrocoagulation 
(e.g., Hyfrecator), surgical excision, or laser ablation may be used.  All of these office-based 
therapies can be painful, cause blistering, scarring and hypo or hyperpigmentation, distort nails 
in the case of periungual warts, risk recurrence, and cost substantial time and money.1,6,8,9 
 
At Mayo Clinic Rochester’s ECH Procedure Clinic as in the Dermatology wart clinic practice, 
intralesional immunotherapy with Candida antigen repeated every 3 weeks up to 5 sessions is the 
third-line therapy for refractory warts. Yet, only 39% of patients in a retrospective review of 
patients receiving Candida antigen in the Mayo Clinic Dermatology practice achieved complete 
wart clearance after up to 6 injections though 41% had a partial response.10 Other studies have 
reported a higher efficacy of Candida antigen. In the original report of use of Candida antigen in 


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a retrospective review by Philips, Ruhl and Pfenninger in 2000 of 149 patients in a Family 
Medicine residency in Michigan, a 72% complete efficacy was reported.11 A prospective study 
of 34 pediatric and adult patients with recurrent or recalcitrant warts who were given 3 injections 
of Candida antigen demonstrated 56% clearance of all warts, and 38% non-response rate.  All of 
the patients in both of these studies had been skin-tested for Candida sensitivity prior to 
treatment.  A retrospective review of 55 pediatric Dermatology clinic patients without skin-
testing mentioned in the paper showed complete resolution in 87%.12 The lower efficacy of the 
Mayo Clinic Candida antigen experience compared to other published data was explained in part 
by the lack of pre-treatment skin test to assure Candida sensitivity, the use of the Candida only 
for recalcitrant warts, and potential misclassification bias as patients were not seen back for a 
final visit to assure clearance but anecdotally (mentioned in the paper) sometimes simply 
cancelled that visit because their warts had cleared.10  
 
In addition to a suboptimal efficacy, patient experiences of injection pain, blistering, swelling, 
rare flu-like symptoms, wheezing, and the low risk of anaphylaxis with Candida (as with any 
antigen or allergen therapy)10, low efficacy, and costs in time, money, lost work productivity 
while returning for repeated treatments warrant a search for alternative approaches . 
 
Vitamin D intralesional injection may be a good alternative. An article in Science in 2006 
discussed the effects of activated vitamin D receptors as immunomodulatory and inhibiting cell 
replication. Activation of toll-like receptors on macrophages induce an antimicrobial peptide 
through an increase in vitamin D receptors and vitamin D-hydroxylase genes, properties of 
vitamin D that may explain its potential mechanism of action as an immune modulator, which 
may represent an efficacious and low cost treatment for the common wart.13 
 
A number of small case reports and case series have suggested efficacy of topical vitamin D in 
regression of cutaneous warts.14-17 Four studies have examined intralesional or sub-lesional 
vitamin D in treatment of recalcitrant warts. Abdel Kareem et al reported the results of a single 
blinded placebo controlled trial using vitamin D3 in a dose of 60,000 IU in 0.2 ml in 2 injections 
given 1 month apart vs a saline placebo in a small population in Turkey of 50 patients ages 12 – 
50 years, most of whom were suffering cutaneous warts of the hands. The methodology of 
recruitment, randomization, and assessment of confounding variables and objective response 
were not described.  They noted side effects of itching and pain in 60% of vitamin D recipients 
(n=30) vs 20% of controls (n= 20). Vitamin D3 resulted in complete wart clearance in 40% of 
those treated vs. 5% in placebo saline control subjects.  They noted a better response in patients 
with fewer and shorter duration of warts and noted regression of distant non-treated warts with 
complete resolution in 2 of the 30 cases as well18. This study added evidence to two prior studies 
using similar doses of vitamin D3 given as an intralesional injection. A retrospective analysis 
case series in Turkey found a 70% clearance after 1 month of recalcitrant plantar warts after one 
treatment session. Treatment involved injections of up to 5 warts per patient each with  0.2 ml of 
vitamin D3 (7.5 mg/ml; 300,000 IU/ml) into the base of the wart using a 21 g needle after pre-
injecting the wart with 0.1 ml prilocaine.  The mean patient age was 28.6 years and mean 
duration of wart was 4.3 years. They observed an 80% complete clearance of plantar warts after 
a second intralesional injection was given to the remaining 3 of 14 patients who had a partial 
response defined as < 50% decrease in lesion size while 3 of 14 patients who failed to respond at 
all did not consent to a second treatment. These above resolution rates were based on 6 month 


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follow up. No patient experienced any adverse effects other than pain during prilocaine injection. 
No hypervitaminosis D or systemic side effects were observed. This study was neither blinded 
nor controlled19. In an open label case series of 64 patients in India, 0.2 to 0.5 ml of vitamin D3 
(15 mg/ml; 600,000 IU/ml) was injected by 26 g needle into the base of up to 5 warts refractory 
to other treatments every 3 weeks for 4 sessions.  Complete clearance was seen in 90% of 
patients.  Roughly half of the warts were palmoplantar and half common warts elsewhere. The 
mean age of these patients was 24 years but ranged 8 – 66 years and mean duration of warts were 
14 months and had not responded to treatment with at least 2 treatment modalities.  All patients 
had transient pain at the time of injection, and a few developed erythema or edema at the 
injection site that resolved within a week.  No signs of hypervitaminosis D or systemic side 
effects were observed. They followed patients for 6 months; 2 of the 64 had recurrence20.  Fathy 
et al recently reported a three arm trial described as a comparative interventional case control 
study of 60 patients in Egypt with ≥3 recalcitrant or recurrent plantar warts. Subjects received 
intralesional injection of vitamin D3, Candida antigen, or saline by 30 g needle using a pre-
injection application of an ice pack for 2 minutes every 3 weeks up to 3 injections in the largest 
wart. The vitamin D3 dose was 60,000 IU in 0.6 ml injected into the base of the largest plantar 
wart. The Candida antigen dose was 0.1 ml and was only used on patients who exhibited a 5mm 
or greater wheal immune response to a 0.1 ml skin test. They found significantly better reduction 
of warts with vitamin D (70% excellent resolution defined as 75-100% reduction of warts) and 
30% non-response compared with both Candida (25% excellent response and 5% very good (50-
75% wart reduction) and 15% good (25-50% reduction)and placebo (no response in any 
patients). In 4 vitamin D subjects who were excellent responders, 35% of warts elsewhere (7 of 
20) showed complete clearance. In 4 Candida subjects who were complete responders, 20% of 
warts elsewhere (4 of coincidentally also 20 total) completely cleared. The only side effect 
reported for vitamin D was pain during injection.21  Kavya et al performed an open label study in 
India of intralesional vitamin D3 in 42 patients with both palmoplantar warts (23) and verruca 
vulgaris (18) and saw a 79% complete response and 14% moderate response. They also used 0.2 
ml of vitamin D3 15 mg/ml (600,000 IU/ml) injected with a 27 g needle into the base of each 
wart pretreated with 0.2 ml of lidocaine 20 mg/ml.22  Another study compared vitamin D3 and 
PPD and used 0.5 ml of vitamin D3 (600,000 IU/ml; 15 mg/ml) injected into the base of each 
wart up to 4 warts (maximum vitamin D3 dose of 1.2 million IU) every 2 weeks for up to 4 
treatments. 80% of patients treated with vitamin D3 injection had complete clearance of warts 
and another 15% showed at least moderate clearance.23 
 
None of these studies had sufficiently robust methodology to demonstrate with confidence that 
vitamin D treatment is efficacious.  All were done in countries outside of the US. All 3 of the 
injection trials used a fairly high dose of vitamin D that may potentially in vitamin D-replete 
individuals result in harm though none was noted. 
1.4 
Dose Rationale  
 
In their 2014 guidelines for wart management, the British Association of Dermatologists authors 
made some clear recommendations for future studies on cutaneous wart therapies.1 They 
recommended single treatment arms rather than combined therapies, sufficient sample size based 
on formal sample size calculations, true randomization of patients to treatment, reporting of 
complete cure of all warts, blinding of outcome evaluation, and follow up both 12 weeks after 
treatment and 6-12 months post-treatment. 


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In previous studies of intralesional vitamin D3 in wart treatments, high dose Vitamin D3 was 
used.18-23  This study proposes to use cholecalciferol (Vitamin D3), injection of 0.3 ml 40,000 
IU, intralesional (specifically at the base of the wart with needle centered under the wart) at 
baseline visit and weeks 4 and 8 as needed. This regimen is similar to the standard of practice 
used at Mayo Clinic Rochester’s ECH Procedure Clinic and in the Dermatology wart clinic 
practice with Candida injections, where standard practice includes intralesional immunotherapy 
with Candida antigen is repeated every 3 weeks up to 5 sessions and is a third-line therapy for 
refractory warts. In addition, our proposed injection regimen is similar to the previous case 
reports and case series which used high dose intralesional injections in 4 week intervals.  
1.5 
Risks and Benefits 
 
Risks of being in the study include the possibility of some pain or discomfort and bleeding at the 
injection site. There is a low risk of infection, scarring, redness or discoloration of the skin, 
swelling or itching at the injection site, as well as the risk of no improvement of the wart. The 
post injection survey will assess if any of these signs or symptoms occur. 
 
This study may not make the subject’s health better, but anything we learn may benefit others in 
the future.  There is a chance the subject may see some improvement in their wart(s). 
2 Study Objectives 
 
We aim to explore the efficacy of intralesional vitamin D injection into cutaneous warts by 
comparing the rates of wart improvement and resolution between a population randomly selected 
to receive either blinded Vitamin D wart injections or placebo. 
3 Study Design 
 
This study is a randomized, double blind, placebo-controlled phase 2 trial of the safety and 
efficacy of Vitamin D3, in the treatment of cutaneous warts.  Subjects will be recruited through 
the Mayo Classifieds, an internet website posting, and/or via flyers and will contact the research 
study coordinators to express interest in the study.  Subject will be asked baseline inclusion 
questions and may take a photo of their index wart to determine eligibility for the study.  Once 
eligibility is determined the study coordinators will consent (either digitally or via paper), enroll 
and randomize the subject. Following enrollment the subject will be seen for examination to 
include measurement of wart(s),photo-documentation, to receive injection of either Vitamin D or 
placebo into the index wart, and to collect baseline data.  Subject visits for intralesional injection 
and follow up will be conducted in exam rooms on Baldwin 4 during regular hours 8 am to 5 pm, 
Monday through Friday.  Baseline data will be collected in the form of a questionnaire to include 
age, sex, presence/absence of immunosuppressive comorbidity or medication use, location(s) of 
warts, approximate time each wart has been present, prior treatments used for these warts and 
month/year those treatments were utilized, size of each wart, and photo-documentation of the 
wart(s) using the Mayo PhotoExam app with paper ruler placed near the wart with images saved 
to the EHR. Size (surface area) of each wart will be calculated based on one-half the mean of the 
measurement of two diameters of the wart at right angles (the mean wart radius) squared and 


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multiplied by pi. Photos of the warts and size measurements of 2 wart diameters at 90 degree 
angles from each other will be collected at baseline and each subsequent visit and the 
measurements entered into an Excel spreadsheet to calculate surface area of each wart at each 
visit. Subjects with more than one wart will be given the choice of which wart they would like 
injected. Only one wart will be treated but the others up to 8 measured, photodocumented and 
observed for evidence of regression during the study. Confirmation of wart measurements by use 
of the PhotoExam images by study Co-I’s blind to treatment and surface area calculations in 
Excel will be compared to those resulting from measurement at the time of the subject visits to 
ensure data integrity. The principle investigator will be responsible for ensuring data integrity by 
comparing measurements recorded at subject visits and measurements based on PhotoExam 
observations by the Co-I’s for the first 3 subjects and then every 10th patient.  Any discrepancy 
will result in an increase in monitoring and discussions with both observers to ensure 
consistency. Patients will return at a scheduled time to the ECH Procedure Clinic for injection 
and post-injection care and education as per the study schedule below. 
 
Subjects will be contacted by email to complete a REDCap survey regarding side effects of 
treatment one week after each visit including pain, pain score, redness, pruritus, malaise, 
myalgia, and fever. These surveys will be reviewed weekly by the PI to ensure subject safety. In 
addition, subjects will be contacted by email to complete a REDCap survey regarding pain and 
pain score each week after the initial survey, until they report for 2 weeks without pain.  This 
survey will also be sent to those subjects who do not receive an injection.  They will be seen 
back 4 weeks and 8 weeks (+/- 1 week) after the first injection to receive an injection in the 
index wart if it is still present (subject may send a photo of their index wart to study coordinator 
to determine if the injection is needed so that medication can be ordered ahead of time), and to 
measure and photo-document all warts.  Subjects will also be seen 12 weeks and 24 weeks (+/- 1 
week) after the first injection to measure and photo-document all warts. Subjects will be 
questioned at each visit to ensure that they have not been using any other wart treatments.  
3.1 
General Description 
Randomized double-blind placebo controlled trial 
3.2 
Number of Subjects 
 
80 (40 intervention, 40 control) 
3.3 
Duration of Participation 
 
Maximum of 168 days. 
3.4 
Primary Study Endpoints 
 
Complete regression of index wart. 
3.5 
Secondary Study Endpoints 
 
Partial regression of index wart as measured in percent surface area lost. 


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Complete or partial regression of up to 7 other warts followed. 
3.6 
Identification of Source Data 
 
The following source data will be directly recorded on the Case Report Form (CRF):  
• Location of wart, time wart present, prior treatments, prior treatment dates 
• Visit, wart appearance, if injection was given, any liquid escape during injection, pain 
score immediately after injection, pain score 1 minute after injection, and pain score 5 
minutes after injection. 
• Concomitant Medications 
• Patient Reported Side effects 
 
The following source data will not be directly collected in the Case Report Form (CRF), but will 
be captured in supportive documentation (study source documents, EMR): 
• PhotoExam wart image 
 
4 Subject Selection Enrollment and Withdrawal 
4.1 
Inclusion Criteria 
 
• Adult ECH patients seen at the Mayo Clinic Rochester practices 
• Patients suffering from one or more cutaneous warts as diagnosed by the examining 
physician at baseline visit on typical diagnostic characteristics 
• Able to provide consent 
• Both recalcitrant and non-recalcitrant warts will be included 
 
4.2 
Exclusion Criteria 
 
• Patients with prior use of home or office-based destructive treatments for this wart(s) in 
the last 1 month with SA or cryotherapy 
• Immunoadjuvant therapy for warts in the last 4 months (e.g Candida) 
• History of vitamin D injection of warts ever 
• High-dose vitamin D supplementation (>4,000 IU daily or equivalent) in the preceding 3 
months 
• Pregnancy or lactation 
• Facial or genital warts 
• Lesions not felt by the examining clinician to be a wart (e.g., corns or calluses) 
• Immunosuppression (to include immunosuppressive medications or conditions as judged 
by the physician evaluating the patient at the baseline visit).  
• Allergy to sesame oil 
4.3 
Subject Recruitment, Enrollment and Screening 
 


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• From the Principal Investigator or Co-Investigator clinical practices 
• Information that is to be given to potential subjects (flyers) 
• Advertisement on Mayo Classifieds and/or internet website posting 
• Screening requirements/Evaluation and documentation of inclusion/exclusion criteria  
o If subject is an adult and has a wart on their skin 
o Wart is not located on face or genitals 
o Subject has not been treated with destructive treatment like Compound w or 
similar products or freezing spray in the last month 
o Subject has not had injection therapy into the wart in the last 4 months 
o Subjects has not been using high does vitamin D (more than 4,000 IU daily) in the 
last 3 months 
o Subject is not pregnant or breast-feeding 
o Subject does not have any immune suppressing disease or is on immune 
suppressing medications 
o Subject is not allergic to sesame oil 
4.4 
Early Withdrawal of Subjects 
 
The subject may decide to withdraw at any time. Subjects should tell the Principal Investigator if 
they decide to withdraw early and they will be advised whether any additional tests need to be 
done for their safety.  
4.4.1 When and How to Withdraw Subjects 
Study subjects will be withdrawn for any subject who is intolerant of intralesional injections or 
has an adverse reaction to include infection, persisting pain, substantial pruritus, malaise, 
myalgias, fever or any other systemic symptoms suspected of being related to the injections. The 
risk of these is very low.   
 
Following each visit, there will be a one week follow up survey of post-injection symptoms 
including pain, pain score, redness, swelling, itching and a one month follow up visit will be 
requested to examine and photodocument the injected wart.  An additional survey will also be 
sent each week after to assess pain and pain score until the subject reports for 2 weeks without 
pain   
 
The risk of hypervitaminosis D in subjects not taking high dose vitamin D with the low doses of 
12,000 IU vitamin D3 that we are using in this study is negligible and will not be monitored. In 
the event of concern for adverse events in study participants (i.e., participant presents to ED with 
symptoms that may be consistent with Vitamin D toxicity such as confusion, polyuria, 
polydipsia, anorexia, vomiting, and muscle weakness or local inflammation at the site of 
injection) Ivana Croghan, PhD will have 24/7 access to REDCap to break the blind and supply 
study drug administration information.   
 
The study will be stopped for any unanticipated problems involving risks to subjects or others 
until these are understood and explained sufficiently to resume the study and for unexplained 
adverse outcomes or life threatening adverse events.  


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4.4.2 Data Collection and Follow-up for Withdrawn Subjects 
 
For all subjects, one week post-injection, follow up surveys (administered by study coordinators 
and completed/answered by subjects) will be reviewed weekly by the principle investigator.  
Additional surveys will be sent each week after until subject reports for 2 weeks without pain. 
5 Study Drug  
5.1 
Description 
Most pharmacologic data relates to oral dosing of vitamin D3.  Studies have found that healthy 
adults reach 25(OH)D3 plasma concentrations of about 20 ng/mL with oral dosing of 600 to 800 
IU vitamin D per day.24,25  Other studies have found that a high single dose of 150,000 IU orally 
raises serum 25(OH)D peaking to 139.0 nmol/l at day 7 then slowly declines, while subjects 
taking 5,000 IU daily peaks to high of 130.5 nmol/l, with no clinical significant elevations in 
calcium or phosphorus in daily oir single high dose regimens.26 
5.2 
Treatment Regimen 
 
Cholecalciferol (Vitamin D3), injection of 0.3 ml 40,000IU, intralesional (specifically at the base 
of the wart with needle centered under the wart) at baseline visit and weeks 4 and 8 as needed. 
5.3 
Method for Assigning Subjects to Treatment Groups 
 
The research pharmacy will perform the randomization and assign a number associated with a 
specific treatment drug. 
5.4 
Preparation and Administration of Study Drug 
 
Subjects will be randomized to receive an intralesional (specifically at the base of the wart with 
needle centered under the wart) injection of 0.3 ml of cholecalciferol (vitamin D3) in sesame oil 
40,000 IU/mL prepared  from a fresh 1.5 ml vial and the unused portion of the vial discarded. 
These injections will be provided in an exam room near the ECH Procedure Clinic on Baldwin 4. 
Controls will receive 0.3 ml of a similarly clear and equally viscous solution of sesame oil 
packaged in the same appearing vials. The wart to be injected will be sprayed for a few seconds 
until it turns white with ethyl chloride to reduce discomfort of the injection.  Injections of 0.3 ml 
will be performed using a 3/4” 30 g needle on a Luer-lock 1 ml syringe under the center of the 
wart being treated  avoiding entering the skin from more than one entry point, repositioning the 
needle tip if liquid runs out from under the wart or from the wart as it is being injected. Any 
escape of injectate during the injection will be recorded. A Band-Aid will be applied and 
participants instructed to remove it after 1 hour unless there is continued bleeding. Vials will be 
ordered from the pharmacy as required for investigational medications for each individual patient 
and picked up by study coordinators from the pharmacy. These vials will either contain active 
drug (vitamin D3 in sesame oil) or placebo (sesame oil)), randomization performed by the 
pharmacy. A spreadsheet will be completed for each study subject who arrives at the procedure 
clinic to record patient study number, Mayo Clinic number, vial A/B (or however pharmacy 


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chooses to identify study drug vs placebo) used, any escape during injection of injectate, and 
pain score immediately, 1 minute and 5 minutes after injection.   
 
 
5.5 
Subject Compliance Monitoring 
 
Patients will be present for face-to-face visits injection of the study medication, which will 
ensure the medication is appropriately administered.  
5.6 
Prior and Concomitant Therapy 
 
Patients with prior use of home or office-based destructive treatments for this wart(s) in the last 1 
month with SA or cryotherapy, immunoadjuvant therapy for warts in the last 4 months (e.g. 
Candida) history of vitamin D injection of warts ever, high-dose vitamin D supplementation 
(>4000 IU daily or equivalent) in the preceding 3 months, or immunosuppressive medications or 
conditions as judged by the physician evaluating the patient at the baseline visit. 
5.7 
Packaging 
 
Cholecalciferol (vitamin D3) in sesame oil 40,000 IU/mL injections will be prepared from a 
fresh 1.5 ml vial and the unused portion of the vial discarded. Controls will receive a similar 
clear and equally viscous solution of sesame oil packaged in the same appearing vials. Study 
drug and placebo are provided by Mayo Production Lab and dispensed by Research Pharmacy.  
90 study drug vials and 90 placebo vials will be provided by Research Pharmacy. 
5.8 
Masking/Blinding of Study  
 
The pharmacy will prepare a stock of vials of vitamin D3 and placebo at intervals when 
requested. At their subsequent visit, participants will receive the same vial containing the same 
unknown as they received at their prior visit.  
5.9 
Receiving, Storage, Dispensing and Return 
 
Subjects presenting for enrollment will be randomized by the pharmacy to receive either placebo 
or vitamin D3 for their injection, procured from the pharmacy at the time of enrollment by 
prescription and prior to each future visit, and picked up by Department of Family Medicine 
research coordinators. 
5.9.1 Receipt of Drug Supplies 
 
Mayo Production Lab will ship the vitamin D3 and placebo to the Research Pharmacy and the 
Department of Family Medicine research coordinators will pick up prior to each study visit. 
 
Upon receipt of the vitamin D3 and/or placebo, an inventory will be performed and a drug 
receipt log will be completed as appropriate for the Research Pharmacy. 


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5.9.2 Storage 
 
Mayo Research Pharmacy will store the vitamin D3 and placebo. 
 
5.9.3 Dispensing of Study Drug 
 
Regular study drug reconciliation will be performed to document drug assigned, drug dispensed, 
drug returns, and drug remaining.  This reconciliation will be logged on the drug reconciliation 
form, and signed and dated by the Research Pharmacy. 
5.9.4 Return or Destruction of Study Drug 
 
At the completion of the study, there will be a final reconciliation of drug shipped, drug 
dispensed, drug returns, and drug remaining.  This reconciliation will be logged on the drug 
reconciliation form, signed and dated.  Any discrepancies noted will be documented and 
investigated, prior to return or destruction of unused study drug.  Drug destroyed on site will be 
documented in the study files. 


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6 Study Procedures 
6.1 
Screening Visit: At this visit once it has been determined if the subject qualifies for this 
study and they agree to participate, they will be randomly assigned by chance (like a coin 
toss) to receive either Vitamin D or placebo injections into the wart of their choice.  
Neither the subject nor the study team can choose which group they’ll be assigned to; we 
will find out at the end of the study.   
6.2 
Baseline Visit 1: The wart will be examined, photographs taken for measurements, 
medications will be reviewed and the subject will complete an initial study questionnaire. 
The wart will be sprayed for a few seconds with ethyl chloride to reduce discomfort just 
prior to receiving the injection. Within a week following the visit, the subject will receive a 
brief survey via email to complete which asks about their symptoms and pain.  Each week 
after, the subject will receive an additional survey asking about pain until they report for 2 
weeks without pain.  
6.3 
Visit 2 and 3 (Week 4 and Week 8) Visits: The subject will receive an injection in the 
index wart if it is still present (subject may send photograph ahead of time to study 
coordinator to determine),.  At the visit, photographs will be taken of all warts for 
measurements, medications reviewed and they will be asked to assess their pain.  A week 
following the visit a survey will be sent via email which asks about their symptoms and 
pain. Each week after, the subject will receive an additional survey asking about pain until 
they report for 2 weeks without pain. 
6.4 
Visit 4 (Week 12): The subject will return to have the wart examined. Photographs will be 
taken of all warts for measurements and medications reviewed.  If the subject still reports 
of pain, a survey will be sent to assess until they report for 2 weeks without pain. 
6.5 
Study Completion (Week 24): The subject will return to have the wart examined. 
Photographs will be taken of all warts for measurements and medications reviewed.  
Payment for their participation will be processed at this time. 
 
Only one wart will receive injections, however up to 8 others may be photographed, measured, 
and observed for any changes during the study.   
 
Photographs of the subjects wart will be added to their electronic medical record. 
 
The subject will be informed which group they were in after the study is completed and 
analyzed. If they continue to have persistent warts, they will be referred back to their primary 
care provider for treatment and provided with education for treatments available over the 
counter. 
 
 
Schedule of Events: 


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Time point 
Screening 
Visit 1 
 
Baseline/ 
Visit 1 
(+ 7 Days) 1 
Visit 2 
(+/- 7 Days)  
Visit 3 
(+/- 7 Days)  
Visit 4 
 (+/- 7 Days) 
Study 
Completion 
(+/- 7 Days) 
Week 
0 
0 
4 
8 
12 
24 
Day 
0 
1 
28 
56 
84 
168 
Informed consent 
X 
 
 
 
 
 
Randomization 
X 
 
 
 
 
 
Vit. D Study 
Questionnaire 
 
X 
 
 
 
 
Inject study medication 
 
X 
X5 
X5 
 
 
Vitamin D Study Visit 
Form 
 
X 
X 
X 
 
 
Take photo of wart 
 
X6 
X6 
X6 
X 
X 
Concomitant Meds.2 
 
X 
X 
X 
X 
X 
REDCap Side effects 
survey3  
 
X 
X 
X 
 
 
REDCap Pain survey4 
 
X 
X 
X 
X 
 
Subject remuneration 
 
 
 
 
 
X 
 
1. Screening and Baseline visit could take place on same day if patient prefers 
2. To ensure subject has not been using any other wart treatments 
3. REDCap side effects survey will be emailed one week after each visit 
4. REDCap pain survey will be emailed one week after the REDCap side effects survey for every week 
until subject reports for 2 weeks without pain 
5. If the index wart is still present 
6. Subject may take photo of index wart ahead of time to determine if injection is needed 
 
7 Statistical Plan 
7.1 
Sample Size Determination 
We can reasonably estimate an efficacy rate of up to 3 intralesional injections of vitamin D into 
recalcitrant warts as high as 90% for and as low as 40%. Given the study design of a 
dichotomous outcome as dependent variable of complete resolution of the wart(s) in the two 
groups to be compared – intervention and control - and an anticipated incidence of 5% 
spontaneous resolution of recalcitrant warts over the course of the 24 weeks of the study and an 
anticipated effect size of the intervention of 35% additional complete resolution based on the 
Abdel Kareem study with a Type I/II Error Rate alpha of 0.05 and power of 80%, we would need 
a sample size of 54 composed of 27 subjects receiving the intervention and 27 controls. We will 
increase enrollment to 30 in each group to account for drop outs. Since Abdel Kareem enrolled 
pediatric patients age 12 and older who tend to have a higher spontaneous resolution of warts 
than adults, we can reasonably base our sample size calculation on his study. If a high percentage 
of the patients we enroll have non-recalcitrant and non-plantar warts, we can assume a  higher 


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spontaneous resolution rate but also anticipate a higher response to the intervention which will 
balance (e.g. sample size calculation for a 25% spontaneous resolution rate in previously 
untreated non-recalcitrant warts but a higher 60% response rate to vitamin D would give a same 
sample size calculation of 60 with 30 subjects in each arm) 
 
Endpoints 
Primary: 
Complete regression of index wart. 
 
Secondary:  
Partial regression of index wart as measured in percent surface area lost. 
Complete or partial regression of up to 7 other warts followed. 
7.2 
Statistical Methods 
 
Descriptive Statistics 
 
There should be no significant temporal bias as season does not appear to affect wart 
refractoriness or resolution (though perhaps the increased vitamin D generated in skin in the 
summer would suggest a higher rate of spontaneous resolution if our hypothesis is correct). 
Secondary outcomes of partial resolution of warts based on visually and palpable size and photo-
documented appearance will be recorded and reported as well. Fisher’s exact test will be used to 
compare effects of placebo vs vitamin D3 injection on wart resolution.   
 
Handling of Missing Data 
 
Adherence to the protocol will be assessed by the study investigators through examination of 
data ensuring randomization and blinding, and self-reports of the study participants. Data from 
participants who for whatever reason deviate from the protocol will be handled by an intention to 
treat method in the final statistical analysis.   
   
Primary Hypothesis: Vitamin D intralesional injection into cutaneous warts results in higher 
rates of complete resolution than saline placebo injection. 
 
Fisher’s exact test will be used to compare effects of placebo vs vitamin D3 injection on wart 
resolution.   
 
Secondary Hypothesis 
 
Partial regression of index wart as measured in percent surface area lost.  
 
Multivariable linear regression will be used to assess the effect of vitamin D injection on final 
wart surface area, adjusting for initial surface area in the model.  
 
Complete or partial regression of up to 7 other warts followed.  


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Fisher’s exact test will be used to compare effects of placebo vs vitamin D3 injection on 
complete resolution of all additional warts. Multivariable linear regression will be used to assess 
the effect of vitamin D injection on final wart surface area of all additional warts, adjusting for 
initial surface area of the additional warts in the model. 
 
Interim Analysis 
 
The study dataset will be routinely monitored by the principle investigator and research 
coordinators to screen for any duplicate data entry and ensure sequential data input.  Any adverse 
events or safety concerns will be immediately reported to the principle investigator and 
documented.  
7.3 
Subject Population(s) for Analysis 
 
• All-treated population:  Any subject randomized into the study that received at least one 
dose of study drug 
8 Safety and Adverse Events 
8.1 
Definitions 
Unanticipated Problems Involving Risk to Subjects or Others (UPIRTSO) 
Any unanticipated problem or adverse event that meets the following three criteria:  
• Serious: Serious problems or events that results in significant harm, (which may be 
physical, psychological, financial, social, economic, or legal) or increased risk for the 
subject or others (including individuals who are not research subjects). These include: (1) 
death; (2) life threatening adverse experience; (3) hospitalization - inpatient, new, or 
prolonged; (4) disability/incapacity - persistent or significant; (5) birth defect/anomaly; (6) 
breach of confidentiality and (7) other problems, events, or new information (i.e. 
publications, DSMB reports, interim findings, product labeling change) that in the opinion 
of the local investigator may adversely affect the rights, safety, or welfare of the subjects 
or others, or substantially compromise the research data, AND 
• Unanticipated: (i.e. unexpected) problems or events are those that are not already 
described as potential risks in the protocol, consent document, not listed in the 
Investigator’s Brochure, or not part of an underlying disease. A problem or event is 
"unanticipated" when it was unforeseeable at the time of its occurrence. A problem or 
event is "unanticipated" when it occurs at an increased frequency or at an increased 
severity than expected, AND 
• Related: A problem or event is "related" if it is possibly related to the research procedures. 
 
 
Adverse Event 
An untoward or undesirable experience associated with the use of a medical product (i.e. drug, 
device, biologic) in a patient or research subject. 
Serious Adverse Event 


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Adverse events are classified as serious or non-serious.  Serious problems/events can be well 
defined and include; 
• death 
• life threatening adverse experience 
• inpatient hospitalization or prolongation of existing hospitalization 
• persistent or significant disability or incapacity 
• substantial disruption of the ability to conduct normal life functions 
• birth defect/congenital anomaly 
 
and/or per protocol may be problems/events that in the opinion of the sponsor-investigator 
may have adversely affected the rights, safety, or welfare of the subjects or others, or 
substantially compromised the research data. 
 
All adverse events that do not meet any of the criteria for serious, should be regarded as non-
serious adverse events.  
 
Adverse Event Reporting Period 
 
For this study, the study treatment follow-up period is defined as 112 days following the last 
administration of study treatment.  
 
Preexisting Condition 
A preexisting condition is one that is present at the start of the study.  A preexisting condition 
should be recorded as an adverse event if the frequency, intensity, or the character of the 
condition worsens during the study period. 
 
General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting 
condition.  At the end of the study, any new clinically significant findings/abnormalities that 
meet the definition of an adverse event must also be recorded and documented as an adverse 
event.  
 
Post-study Adverse Event 
All unresolved adverse events should be followed by the sponsor-investigator until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained.  At the last 
scheduled visit, the sponsor-investigator should instruct each subject to report, to the sponsor-
investigator, any subsequent event(s) that the subject, or the subject’s personal physician, 
believes might reasonably be related to participation in this study.  
 
 
Abnormal Laboratory Values 
 
There will be no routine clinical laboratory monitoring for the purpose of this study.  However, if 
subjects present with signs or symptoms of vitamin D toxicity to a medical care provider, values 
for standard laboratory workup including 25(OH) vitamin D concentration, calcium, phosphorus, 
creatinine would be monitored as well as any follow-up labs within the study’s follow-up period. 


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A clinical laboratory abnormality will be documented as an adverse event if any of these values 
are found to be above normal ranges.   
 
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be 
documented and reported as a serious adverse event unless specifically instructed otherwise in 
this protocol.  Any condition responsible for surgery should be documented as an adverse event 
if the condition meets the criteria for an adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an 
adverse event in the following circumstances: 
• Hospitalization for diagnostic or elective surgical procedures for a preexisting condition.   
8.2 
Recording of Adverse Events 
At each contact with the subject, the study team must seek information on adverse events by 
specific questioning and, as appropriate, by examination.  Information on all adverse events 
should be recorded immediately in the source document, and also in the appropriate adverse 
event section of the adverse event worksheet.  All clearly related signs, symptoms, and abnormal 
diagnostic, laboratory or procedure results should recorded in the source document. 
 
All adverse events occurring during the study period must be recorded.  The clinical course of 
each event should be followed until resolution, stabilization, or until it has been ultimately 
determined that the study treatment or participation is not the probable cause.  Serious adverse 
events that are still ongoing at the end of the study period must be followed up, to determine the 
final outcome.  Any serious adverse event that occurs during the Adverse Event Reporting 
Period and is considered to be at least possibly related to the study treatment or study 
participation should be recorded and reported immediately. 
8.3 
Reporting of Serious Adverse Events and Unanticipated Problems 
 
When an adverse event has been identified, the study team will take appropriated action 
necessary to protect the study participant and then complete the Study Adverse Event Worksheet 
and log.  The sponsor-investigator will evaluate the event and determine the necessary follow-up 
and reporting required. 
8.3.1 Sponsor-Investigator reporting: notifying the Mayo IRB 
 
The sponsor-investigator will report to the Mayo IRB any UPIRTSOs and Non-UPIRTSOs 
according to the Mayo IRB Policy and Procedures. 
 
8.3.2 Sponsor-Investigator reporting: Notifying the FDA 
 
The sponsor-investigator will report to the FDA all unexpected, serious suspected adverse 
reactions according to the required IND Safety Reporting timelines, formats and requirements. 
 


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Unexpected fatal or life threatening suspected adverse reactions where there is evidence to 
suggest a causal relationship between the study drug/placebo and the adverse event, will be 
reported as a serious suspected adverse reaction.  This will be reported to the FDA on FDA Form 
3500A, no later than 7 calendar days after the sponsor-investigator’s initial receipt of the 
information about the event. 
 
Other unexpected serious suspected adverse reactions where there is evidence to suggest a causal 
relationship between the study drug/placebo and the adverse event, will be reported as a serious 
suspected adverse reaction.  This will be reported to the FDA on FDA Form 3500A, no later than 
15 calendar days after the sponsor-investigator’s initial receipt of the information about the 
event. 
 
Any clinically important increase in the rate of serious suspected adverse reactions over those 
listed in the protocol or product insert will be reported as a serious suspected adverse reaction.  
This will be reported to the FDA on FDA Form 3500A no later than 15 calendar days after the 
sponsor-investigator’s initial receipt of the information about the event. 
 
The sponsor-investigator must also notify the FDA (and sponsors  must notify all participating 
investigators) in an IND safety report of potential serious risks, from clinical trials or any other 
source, as soon as possible, but in no case later than 15 calendar days after the sponsor 
determines that the information qualifies for reporting under § 312.32(c)(1)(i)-(iv). 
 
Findings from other studies in human or animals that suggest a significant risk in humans 
exposed to the drug will be reported.  This will be reported to the FDA on FDA Form 3500A, no 
later than 15 calendar days after the sponsor-investigators initial receipt of the information about 
the event. 
8.4 
Unmasking/Unblinding Procedures 
 
In the event of concern for adverse events in study participants (i.e., participant presents to 
emergency department with symptoms that may be consistent with vitamin D toxicity such as 
confusion, polyuria, polydipsia, anorexia, vomiting, and muscle weakness or local inflammation 
at the site of injection) Ivana Croghan, PhD will have 24/7 access to REDCap to break the blind 
and supply study drug administration information.  Documentation of this will be kept in the 
subject’s source document. 
8.5 
Medical Monitoring 
It is the responsibility of the Principal Investigator to oversee the safety of the study at his site.  
This safety monitoring will include careful assessment and appropriate reporting of adverse 
events as noted above, as well as the construction and implementation of a site data and safety-
monitoring plan (see section 10  “Study Monitoring, Auditing, and Inspecting”).  Medical 
monitoring will include a regular assessment of the number and type of serious adverse events. 


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9 Data Handling and Record Keeping 
9.1 
Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  
Those regulations require a signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization.  For subjects that have revoked authorization to collect or use PHI, attempts 
should be made to obtain permission to collect at least vital status (long term survival status that 
the subject is alive) at the end of their scheduled study period. 
9.2 
Source Documents 
Source data is all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial.  Source 
data are contained in source documents.  Examples of these original documents, and data records 
include: hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ 
diaries or evaluation checklists, pharmacy dispensing records, recorded data from automated 
instruments, copies or transcriptions certified after verification as being accurate and complete, 
microfiches, photographic negatives, microfilm or magnetic media, x-rays, subject files, and 
records kept at the pharmacy, at the laboratories, and at medico-technical departments involved 
in the clinical trial. 
9.3 
Case Report Forms 
 
The study case report form (CRF) is the primary data collection instrument for the study.  All 
data requested on the CRF must be recorded.  All missing data must be explained.  If a space on 
the CRF is left blank because the procedure was not done or the question was not asked, write 
“N/D”.  If the item is not applicable to the individual case, write “N/A”.  All entries should be 
printed legibly in ink.  If any entry error has been made, to correct such an error, draw a single 
straight line through the incorrect entry and enter the correct data above it.  All such changes 
must be initialed and dated.  Do not erase or use “white-out” for errors.  For clarification of 
illegible or uncertain entries, print the clarification above the item, then initial and date it.  If the 
reason for the correction is not clear or needs additional explanation, neatly include the details to 
justify the correction. 
 
 
 
Data Management 
 


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Subject inclusion criteria will be ascertained by study coordinators at enrollment during the 
screening visit. A questionnaire completed at this time will be reviewed to ensure both verbal 
and written affirmation of inclusion criteria and absence of exclusion criteria. In addition to 
completion of the questionnaire by the study subjects, all warts will be photo-documented at 
baseline and at each follow up visit with ruler placed near the wart and those images used for 
confirmation of wart measurements and surface area calculations by the study PI or Co-
Investigators blinded to treatment to ensure accurate surface area calculations. Measurements of 
2 diameters of each wart will be entered into REDCap for standardized surface area calculations.  
 
Data Security and Confidentiality 
 
Data will be stored in a password protected encrypted file on a study laptop or desktop computer 
kept in the Department of Family Medicine Research Office in Baldwin and automatically 
backed up several times daily. Data will be kept for 3 years after completion of the study. Access 
to the computer will be limited to the PI, Co-I’s, and study coordinators. Images of the warts will 
be stored in a secure electronic form in Epic for each patient’s PhotoExam wart image.  
 
Data Quality Assurance 
 
Department of Family Medicine research study coordinators will monitor the data closely 
throughout the study, to ensure the data in the database accurately reflects data on the CRFs. 
 
Data Clarification Process 
 
Adherence to the protocol will be assessed by the study investigators through examination of 
data ensuring randomization and blinding, and self-reports of the study participants. Data from 
participants who for whatever reason deviate from the protocol will be handled by an intention to 
treat method in the final statistical analysis.  The primary investigator will evaluate any data 
queries and discuss discrepancies with any investigators involved with that particular data 
acquisition.     
9.4 
Records Retention 
The sponsor-investigator will maintain records and essential documents related to the conduct of 
the study.  These will include subject case histories and regulatory documents. 
 
The subjects information will be coded by unique numbers, research materials will be stored in 
locked cabinets, and data stored electronically on password-protected computers.  
 
The sponsor-investigator will retain the specified records and reports for whichever is longer: 
1. Up to 2 years after the marketing application is approved for the drug; or, if a marketing 
application is not submitted or approved for the drug, until 2 years after shipment and 
delivery of the drug for investigational use is discontinued and the FDA has been so 
notified. OR 
2. As outlined in the Mayo Clinic Research Policy Manual –“Retention of and Access to 
Research Data Policy” http://mayocontent.mayo.edu/research-policy/MSS_669717   


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10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
 
The investigator will allocate adequate time for such monitoring activities.  The Investigator will 
also ensure that the monitor or other compliance or quality assurance reviewer is given access to 
all the study-related documents and study related facilities (e.g. pharmacy, diagnostic laboratory, 
etc.), and has adequate space to conduct the monitoring visit. 
10.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, the 
sponsor, and government regulatory agencies, of all study related documents (e.g. source 
documents, regulatory documents, data collection instruments, study data etc.).  The investigator 
will ensure the capability for inspections of applicable study-related facilities (e.g. pharmacy, 
diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable compliance offices. 
11 Ethical Considerations 
This study is to be conducted according to United States government regulations and 
Institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted local Institutional 
Review Board (IRB), in agreement with local legal prescriptions, for formal approval of the 
study.  The decision of the IRB concerning the conduct of the study will be made in writing to 
the sponsor-investigator before commencement of this study. 
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in this 
study.  This consent form will be submitted with the protocol for review and approval by the IRB 
for the study.  The formal consent of a subject, using the Approved IRB consent form, must be 
obtained before that subject undergoes any study procedure.  The consent form must be signed 
by the subject or the subject’s legally authorized representative, and the individual obtaining the 
informed consent. 
12 Study Finances 
12.1 Funding Source 
 
This study is financed through the Parker D. Sanders & Isabella G. Sanders Professorship funds 
and departmental small grant funds. 
12.2 Subject Stipends or Payments 
 
Each participant will receive $25 per study visit completed and will be paid at study completion. 


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13 Publication Plan 
 
Stephen Merry, MD, MPH, holds the primary responsibility for the publication of the results for 
the study.   
 
The study will be registered on ClinicalTrials.gov prior to subject recruitment and enrollment.  
The results will be posted to ClinicalTrials.gov within 12 months of final data collection for the 
primary outcome.  
14 References 
 
1. 
Sterling, J.C., et al., British Association of Dermatologists' guidelines for the 
management of cutaneous warts 2014. Br J Dermatol, 2014. 171(4): p. 696-712. 
2. 
Gibbs, S. and I. Harvey, Topical treatments for cutaneous warts. Cochrane Database Syst 
Rev, 2006(3): p. CD001781. 
3. 
Massing, A.M. and W.L. Epstein, Natural history of warts. A two-year study. Arch 
Dermatol, 1963. 87: p. 306-10. 
4. 
Kwok, C.S., R. Holland, and S. Gibbs, Efficacy of topical treatments for cutaneous 
warts: a meta-analysis and pooled analysis of randomized controlled trials. Br J 
Dermatol, 2011. 165(2): p. 233-46. 
5. 
Bruggink, S.C., et al., Cryotherapy with liquid nitrogen versus topical salicylic acid 
application for cutaneous warts in primary care: randomized controlled trial. CMAJ, 
2010. 182(15): p. 1624-30. 
6. 
Cockayne, S., et al., Cryotherapy versus salicylic acid for the treatment of plantar warts 
(verrucae): a randomised controlled trial. BMJ, 2011. 342: p. d3271. 
7. 
Mulhem, E. and S. Pinelis, Treatment of nongenital cutaneous warts. Am Fam Physician, 
2011. 84(3): p. 288-93. 
8. 
Gibbs, S., et al., Local treatments for cutaneous warts: systematic review. BMJ, 2002. 
325(7362): p. 461. 
9. 
Bruggink, S.C., et al., Current choices in the treatment of cutaneous warts: a survey 
among Dutch GP. Fam Pract, 2010. 27(5): p. 549-53. 
10. 
Alikhan, A., J.R. Griffin, and C.C. Newman, Use of Candida antigen injections for the 
treatment of verruca vulgaris: A two-year mayo clinic experience. J Dermatolog Treat, 
2016. 27(4): p. 355-8. 
11. 
Phillips, R.C., et al., Treatment of warts with Candida antigen injection. Arch Dermatol, 
2000. 136(10): p. 1274-5. 
12. 
Maronn, M., et al., One-year experience with candida antigen immunotherapy for warts 
and molluscum. Pediatr Dermatol, 2008. 25(2): p. 189-92. 
13. 
Liu, P.T., et al., Toll-like receptor triggering of a vitamin D-mediated human 
antimicrobial response. Science, 2006. 311(5768): p. 1770-3. 
14. 
Egawa, K. and T. Ono, Topical vitamin D3 derivatives for recalcitrant warts in three 
immunocompromised patients. Br J Dermatol, 2004. 150(2): p. 374-6. 
15. 
Mitsuhashi, Y., et al., Topical vitamin D3 is effective in treating senile warts possibly by 
inducing apoptosis. J Dermatol, 2005. 32(6): p. 420-3. 
16. 
Mitsuhashi, Y., [New aspects on vitamin D3 ointment; treatment of senile warts with 
topical application of active forms of vitamin D3]. Clin Calcium, 2004. 14(10): p. 141-4. 


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17. 
Imagawa, I. and H. Suzuki, Successful treatment of refractory warts with topical vitamin 
D3 derivative (maxacalcitol, 1alpha, 25-dihydroxy-22-oxacalcitriol) in 17 patients. J 
Dermatol, 2007. 34(4): p. 264-6. 
18. 
Kareem, I.M.A., et al., Effectiveness of intralesional vitamin D3 injection in the treatment 
of common warts: Single-blinded placebo-controlled study. Dermatol Ther, 2019: p. 
e12882. 
19. 
Aktas, H., et al., Intralesional Vitamin D Injection May Be an Effective Treatment Option 
for Warts. J Cutan Med Surg, 2016. 20(2): p. 118-22. 
20. 
Raghukumar, S., et al., Intralesional Vitamin D3 Injection in the Treatment of 
Recalcitrant Warts: A Novel Proposition. J Cutan Med Surg, 2017. 21(4): p. 320-324. 
21. 
Fathy, G., M.A. Sharara, and A.H. Khafagy, Intralesional vitamin D3 versus Candida 
antigen immunotherapy in the treatment of multiple recalcitrant plantar warts: A 
comparative case-control study. Dermatol Ther, 2019: p. e12997. 
22. 
Kavya, M., et al., Safety and Efficacy of Intralesional Vitamin D3 in Cutaneous Warts: 
An Open Uncontrolled Trial. J Cutan Aesthet Surg, 2017. 10(2): p. 90-94. 
23. 
Singh, S., et al., A comparative study between intralesional PPD and vitamin D3 in 
treatment of viral warts. International Journal of Research in Dermatology, 2018. 
24. Bischoff-Ferrari H.A. et al.  Benefit–risk assessment of vitamin D supplementation. 
Osteoporos Int, 21 (2010), pp. 1121-1132  
25. Gallagher, J.C. et al.  Dose response to vitamin D supplementation in postmenopausal 
women: a randomized trial. Ann Intern Med, 156 (2012), pp. 425-437 
26. Meekins, ME SS et al. Pharmacokinetics of daily versus monthly vitamin D3 
supplementation in non-lactating women.  European Journal of Clinical Nutrition (2014) 
68, 632–634.