What Is Psoriasis?

Psoriasis (derived from the Greek word for itch) is a chronic, genetic, non-contagious skin disorder. Psoriasis is believed to be an autoimmune disease in which white blood cells called T cells become abnormally activated and move through the blood stream into the skin, where they trigger inflammation and excessive skin cell production. Over time, the overgrowth of skin cells accumulate as a layer of dead white- or silver-colored scales on the surface of the skin. The surface of the skin becomes inflamed with red, thickened areas (with silvery scales), which primarily appear on the scalp, elbows, knees and lower back.

In approximately 35% of cases, someone else in the family has had psoriasis, suggesting that it is inherited. There is still no effective cure for this disease, which can become severe and even lead to death in a small number of cases. Psoriasis affects approximately 20 million people worldwide, including 5 to 7 million Americans. Annual incidence rates are thought to run at up to 500,000 new cases worldwide (150,000 in the U.S.).* The National Psoriasis Foundation reports that physicians see more than 1.5 million Americans every year for psoriasis.

What is Psoriatic Arthritis?

In addition, approximately 15 to 20 percent of psoriasis sufferers also have a form of arthritis called psoriatic arthritis (PsA). The arthritic stiffness, pain, swelling and tenderness usually affects the joints and surrounding soft tissues of the wrists, knees, ankles, lower back and neck. Unlike rheumatoid arthritis, PsA affects men and women equally and is typically diagnosed in people between the ages of 30 and 50. PsA is also thought to have a genetic link, as up to 40 percent of patients have a family history of psoriasis or arthritis. As with psoriasis itself, there are several forms of PsA that vary in the location and severity of joint damage. PsA is difficult to diagnose in its milder forms – although it can develop quickly, leading to a progressively disabling disease if untreated.

Several Forms of Psoriasis Exist**

The most common form of psoriasis is called plaque psoriasis and occurs in approximately 80 percent of people affected by psoriasis. The "plaques" are the patches of red, raised skin found in this type of psoriasis. Several other, less common types are also found:

•Guttate psoriasis — appears as small, red spots on the skin, usually on the trunk and limbs. This type is more frequently diagnosed in children and young adults and could be triggered by infection.

•Erythrodermic psoriasis — a particularly inflammatory form of psoriasis, causing painful and itchy red patches of skin that usually shed.

•Generalized pustular psoriasis — frequently appears as red areas of skin containing pus-filled pimples (pustules) or blisters. This form of psoriasis tends to flare in cycles, causing painful, tender areas of skin.

•Localized pustular psoriasis — usually affects the hands and feet, causing pustules that later become dry and brown and eventually begin to peel away.

•Inverse (flexural) psoriasis — develops in skin folds, such as the armpits. This form of psoriasis causes the appearance of smooth, red, inflamed skin, but without scaling, and is experienced most often and is most severe in overweight people.

•Acropustulosis — a rare form of psoriasis primarily affecting the fingers and toes (including the nails and bone), causing pain.

•In addition, approximately 50 percent of people with active psoriasis have psoriatic changes in their fingernails and/or toenails, resulting in pitting, discoloration or even loss of the nail.

*The National Psoriasis Foundation, http://www.psoriasis.org/files/pdfs/press/npfsurvey.pdf, Accessed 12/31/03.

**The National Psoriasis Foundation, http://www.psoriasis.org/facts/psoriasis/, Accessed 12/31/03.

The treatment of psoriasis is tailored to meet the severity of the disease. The more severe disease usually requires stronger treatments with more side effects. The three main types of psoriasis treatment are as follows:

Topical therapy — Primarily prescribed for mild-to-moderate disease and includes steroids, coal tar/tar shampoos, calcipotriene (synthetic vitamin D3), vitamin A, anthralin (used in combination with ultra-violet B (UVB) light for more severe psoriasis), keratolytics (salicyclic acid, lactic acid, urea), and sunlight (UVB).

Phototherapy — In more moderate-to-severe forms of psoriasis, or localized areas of stubborn plaques, several cycles of UVB over a period of up to two months can be used. Sometimes a prescription medication called psoralen given in combination with UVA (the combination is referred to as PUVA). PUVA can clear or significantly improve psoriasis for more than 75% of patients, leading to extended remissions in some cases. However, a key risk factor is that long-term PUVA therapy increases a person’s risk of developing skin cancer.

Systemic medicines — Systemic medicines are generally the last resort of psoriasis treatment and are primarily used to treat the most severe forms of the disease:

•Methotrexate (MTX) — the most commonly prescribed for severe and disabling psoriasis. MTX has been proven to be effective in clearing or greatly improving most types of psoriasis. However, MTX causes several side effects including nausea, fatigue, loss of appetite, and mouth sores and has been shown to cause liver damage in periods of extended use.

•Cyclosporine — a medicine used for treating severe psoriasis in people unable to take other systemic treatments. Although effective, it can raise blood pressure and cause severe kidney damage in periods of long-term use and therefore administration is generally restricted to periods of less than one year

•Oral retinoids — related to vitamin A, Acitretin (Soriatane®) is the only approved retinoid for the treatment of severe psoriasis. Although effective for the less common pustular and erythrodermic forms of psoriasis, it is less effective for plaque psoriasis than most alternative therapies.

•Efalizumab (Raptiva™) — is an injectable medicine approved for the treatment of adults with moderate to severe plaque psoriasis. Raptiva works by shutting off the abnormal T cell activity, preventing the T cells from moving into the skin.

•Alefacept (Amevive®) – is an injectable medicine for the treatment of adults with moderate-to-severe plaque psoriasis. Amevive works by blocking the abnormal activation of T cells.

Psoriatic Arthritis: Treatments

Initial treatment of Psoriatic Arthritis (PsA) generally consists of the use of non-steroidal anti-inflammatories (NSAIDs), followed by switching to methotrexate for more advanced PsA. More severe PsA will be treated in one of the following ways.

•Methotrexate — may improve the arthritis and skin problems of PsA.

•Corticosteroids — by injection directly into the joints.

•Cyclosporine — has been shown to be effective, but due to the associated kidney side effects, it is reserved for people with progressive PsA that has not responded to other treatments.

•Sulfasalazine — shown to slow or halt the progression of some types of arthritis.

•Etanercept (Enbrel®) — is for use (in combination with methotrexate) in people with PsA who do not respond well to methotrexate alone. Enbrel works by blocking the action of TNF, one of the key blood factors that cause joint swelling.

Caremark understands that people with psoriasis and psoriatic arthritis have special needs. We’ll make sure you get your prescribed Raptiva® for psoriasis or Enbrel® for psoriatic arthritis or other medicine prescribed by your doctor from our Specialty Pharmacy; along with the medically necessary supplies you need to safely and correctly administer your treatment.

Caremark has more than 25 years experience with oral, injectable and infused medicines, working closely with each doctor, clinician and participant to make sure medicines are administered as effectively as possible. In addition to providing your prescribed medicines and supplies, Caremark Specialty Pharmacy Services helps in many other ways:

Education. We’ll provide you with the information and resources to learn all about psoriasis, the medicines, lifestyle issues, ways to manage your disease and treatment, and the importance of following your treatment plan.

Customized Care. Sticking to your treatment plan is a top priority, so Caremark assigns each participant a pharmacist-led CareTeam. Your CareTeam will review your medicine schedule, work with you to resolve any injection-related issues, discuss proper waste disposal, and stress the importance of managing your own therapy. We’ll also coordinate nursing services when requested and approved.

Ongoing Communication. Your CareTeam will call you periodically to answer questions, help with treatment issues, schedule shipments of your medicine and support you in your treatment plan. We also communicate regularly with the manufacturers of these medicines so we can keep you informed about additional support materials and services.

Discreet Deliveries. We know how important your privacy is, so we’ll ship your medicines in secure, plain, temperature-controlled packaging to your home, office or doctor’s office—at your direction.

24-Hour Availability. We’re here when you need us. Our Specialty Pharmacy pharmacists are available 24 hours a day, 365 days a year, in case of emergencies.

With Caremark, you’ll have a team of experts on your side, helping you get professional, caring and cost-effective service. If you would like to find out more about our services, please call CaremarkConnect® toll-free at 1-800-237-2767.

Navigating Insurance

To inquire about or begin services with Caremark Specialty Pharmacy Services, please call or have your healthcare provider call CaremarkConnect® at 1-800-237-2767. You may also begin the enrollment process here. Once you fill out the requested information, one of our staff of specialists will contact you. Regardless of how you begin the process, our staff of specialists will work with you and your insurance carrier to confirm coverage for your treatment. We’ll conduct a full benefits investigation for you for the medicines you may need.

A specialist will assist you with:

•Securing coverage for your new prescription

•Determining your coverage and minimizing out-of-pocket costs

•Processing insurance paperwork and coordinating benefits

•Handling prior authorization issues

•Obtaining all necessary authorizations

•Communicating your financial obligations verbally and in writing

•Assisting in the coordination of home administration services

•Arranging delivery of your medicines

•Coordinating the start of therapy with your doctor

To explore financial coverage alternatives when insurance is not available to you, we offer Caremark Customer Assistance at 1-800-331-7171. Our staff of specialists will work with you to explore coverage alternatives when insurance is not an option. Please feel free to call us with questions or problems.

To inquire about or begin services with Caremark Specialty Pharmacy Services, please call or have your healthcare provider call CaremarkConnect® at 1-800-237-2767. You may also begin the enrollment process here. Once you fill out the requested information, one of our staff of specialists will contact you. Regardless of how you begin the process, our staff of specialists will work with you and your insurance carrier to confirm coverage for your treatment. We'll conduct a full benefits investigation for you for the medicines you may need.

Listed below are sites that you might find helpful in searching for information about psoriasis. Remember, your doctor is one of the best sources of information about your condition.

RAPTIVA™ (efalizumab)

National Psoriasis Foundation

National Institute of Arthritis and Musculoskeletal and Skin Diseases

American Academy of Dermatology

* Caremark does not operate the Web sites/organizations listed here, nor is it responsible for the availability or reliability of their content. These listings do not imply or constitute an endorsement, sponsorship, or recommendation by Caremark. Information from these Web sites/organizations is not a substitute for medical advice or treatment. Discuss any information you find with your doctor or healthcare professional.

Copyright © 2005 Consumer Health Interactive

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