Synalar

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Synalar on Prescriptsy

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Synalar is a topical corticosteroid preparation containing fluocinolone acetonide 0.025%.

It is classified as a potent corticosteroid in the British National Formulary (BNF) and is prescribed for the treatment of inflammatory skin conditions including eczema (atopic dermatitis, contact dermatitis, discoid eczema), psoriasis, and other steroid-responsive dermatoses that have not responded adequately to milder corticosteroids.

Synalar is available as both a cream and an ointment formulation, and it is a prescription-only medicine (POM) in the United Kingdom.

Inflammatory skin conditions are among the most common reasons for GP consultations in the UK.

Atopic eczema alone affects approximately 1 in 5 children and 1 in 10 adults. Psoriasis affects around 2% of the UK population.

These conditions cause significant physical discomfort including persistent itching, soreness, and sleep disruption, as well as psychological distress and reduced quality of life.

Topical corticosteroids remain the cornerstone of treatment for inflammatory skin flares, used alongside regular emollients to restore and maintain the skin barrier.

This page provides a comprehensive clinical guide to Synalar, covering how it works, dosage instructions, side effects, safety warnings, and how to obtain a prescription in the United Kingdom.

Important safety information about Synalar

Before reading further, please note these essential safety points.

• Synalar is a potent topical corticosteroid. Use it only on the affected areas and for the shortest duration necessary to control your condition.
• Do not use Synalar on the face for more than 5 days unless directed by a dermatologist.
• Do not apply Synalar to untreated skin infections (bacterial, fungal, or viral).
• Do not use occlusive dressings over Synalar unless specifically instructed by your prescriber.
• If your skin condition worsens or shows signs of infection during treatment, stop using Synalar and consult your prescriber.

Understanding inflammatory skin conditions

Eczema (dermatitis) is a group of conditions characterised by inflammation, itching, and disruption of the skin barrier.

Atopic eczema is the most common form, driven by a combination of genetic factors (including filaggrin gene mutations that impair the skin barrier) and immune dysregulation (a T-helper 2 dominant inflammatory response).

The defective skin barrier allows allergens and irritants to penetrate, triggering inflammation and itch. Scratching further damages the barrier, creating the itch-scratch cycle that perpetuates the condition.

Other forms include contact dermatitis (allergic or irritant), seborrhoeic dermatitis, varicose eczema, and discoid (nummular) eczema.

Psoriasis is a chronic immune-mediated inflammatory disease characterised by well-defined, raised, red plaques covered with silvery-white scales.

The pathology involves accelerated epidermal turnover (keratinocyte proliferation completing in 3 to 5 days instead of the normal 28 to 30 days), driven by a T-helper 17 and T-helper 1 inflammatory response.

Common sites include the elbows, knees, scalp, lower back, and nails.

Psoriasis has a significant impact on quality of life and is associated with psoriatic arthritis, cardiovascular disease, and metabolic syndrome.

How Synalar works

Fluocinolone acetonide is a synthetic fluorinated corticosteroid.

The addition of a fluorine atom at the 9-alpha position and an acetonide group at the 16,17 position increases its anti-inflammatory potency and resistance to local metabolic breakdown compared with natural cortisol.

When applied to the skin, fluocinolone acetonide penetrates the stratum corneum and binds to intracellular glucocorticoid receptors in the cytoplasm of keratinocytes, fibroblasts, Langerhans cells, and infiltrating lymphocytes.

The activated receptor-steroid complex translocates to the cell nucleus, where it modulates gene transcription.

The anti-inflammatory effects involve both transactivation (switching on anti-inflammatory genes) and transrepression (switching off pro-inflammatory genes). Transrepression is considered the more important mechanism for clinical efficacy.

Fluocinolone acetonide suppresses the transcription of pro-inflammatory cytokines including interleukin-1, interleukin-6, tumour necrosis factor-alpha, and interferon-gamma.

It inhibits the production of prostaglandins and leukotrienes by suppressing phospholipase A2 through the induction of lipocortin-1. It reduces capillary permeability (vasoconstriction), decreasing oedema and erythema.

It also suppresses the migration and activity of inflammatory cells including lymphocytes, monocytes, and eosinophils.

The antipruritic effect (itch reduction) results from the suppression of inflammatory mediators that stimulate sensory nerve endings in the skin. The vasoconstrictive effect reduces visible redness, and the antiproliferative effect helps to normalise the accelerated epidermal turnover seen in psoriasis.

The BNF potency scale for topical corticosteroids

The British National Formulary classifies topical corticosteroids into four potency groups. Mild corticosteroids include hydrocortisone 0.5% to 2.5%, suitable for mild eczema, facial use, and children.

Moderately potent corticosteroids include clobetasone butyrate 0.05% (Eumovate), used for moderate eczema on the body.

Potent corticosteroids include fluocinolone acetonide 0.025% (Synalar), betamethasone valerate 0.1% (Betnovate), and mometasone furoate 0.1% (Elocon), used for more severe or resistant eczema and psoriasis.

Very potent corticosteroids include clobetasol propionate 0.05% (Dermovate), reserved for the most resistant conditions and specialist use only.

The choice of potency depends on the severity of the condition, the body site being treated, the patient's age, and the duration of treatment needed.

As a general principle, the lowest potency that achieves disease control should be used for the shortest duration necessary.

Thin-skinned areas (face, eyelids, flexures, genitalia) require milder preparations, while thicker skin (palms, soles, scalp) may tolerate potent or very potent preparations more safely.

Synalar formulations

Synalar is available as a cream and an ointment, both containing fluocinolone acetonide 0.025%.

The cream formulation is an oil-in-water emulsion that spreads easily, absorbs relatively quickly, and is cosmetically acceptable for daytime use.

It is most suitable for moist, weeping, or exudative areas of eczema where a lighter preparation is preferred.

The ointment formulation is a water-in-oil preparation that is greasier and more occlusive.

It is better suited for dry, thickened, or lichenified skin, as the occlusive base enhances hydration and drug penetration.

In general, ointments are more effective than creams for the same active ingredient concentration because the occlusive base increases percutaneous absorption.

Synalar is also available in combination products. Synalar C contains fluocinolone acetonide 0.025% with clioquinol 3%, an antimicrobial agent for eczema complicated by mild bacterial or fungal infection.

Synalar N contains fluocinolone acetonide 0.025% with neomycin sulphate 0.5%, an aminoglycoside antibiotic for eczema with bacterial superinfection.

These combination products should only be used when infection is confirmed or strongly suspected, and treatment duration should be limited to 7 days to avoid antibiotic resistance and sensitisation.

Clinical evidence for topical corticosteroids in eczema and psoriasis

Topical corticosteroids are supported by decades of clinical evidence and remain the first-line anti-inflammatory treatment for eczema flares, as recommended by NICE guideline CG57 (atopic eczema in under-12s) and NICE guideline NG169 (atopic eczema in adults).

The guidelines recommend a stepwise approach, starting with emollients alone and escalating through mild, moderately potent, and potent corticosteroids as needed.

For psoriasis, NICE guideline CG153 recommends potent topical corticosteroids as first-line treatment for plaque psoriasis on the body, often used in combination with a vitamin D analogue (calcipotriol).

A systematic review published in the British Medical Journal found that potent topical corticosteroids were significantly more effective than mild corticosteroids for moderate-to-severe eczema, with no significant increase in local side effects when used for short courses (up to 4 weeks).

Weekend (proactive) maintenance therapy with potent topical corticosteroids applied twice weekly to previously affected areas has been shown to reduce relapse rates in chronic eczema, and is recommended in NICE guidelines.

Dosage and administration

Apply a thin layer of Synalar to the affected area once or twice daily as directed by your prescriber.

Use the fingertip unit (FTU) method to measure the correct amount.

One FTU is the amount squeezed from a standard tube along an adult index finger from the tip to the first crease, and covers an area approximately twice the size of an adult palm.

The table below provides approximate FTU guidance for adults.

• Face and neck: 2.5 FTU
• One hand (both surfaces): 1 FTU
• One arm: 3 FTU
• One leg: 6 FTU
• Trunk (front): 7 FTU
• Trunk (back): 7 FTU

Apply to clean, dry skin. If using an emollient, apply the emollient first and wait 15 to 30 minutes before applying Synalar.

This allows the emollient to absorb and avoids diluting the corticosteroid. Do not cover the treated area with airtight dressings unless specifically instructed by your prescriber.

Treatment should be for the shortest duration necessary. A typical treatment course for an eczema flare is 7 to 14 days.

Review with your prescriber if the condition has not improved within 7 days or if frequent courses are needed.

When the flare settles, step down to a milder corticosteroid or emollient alone.

Side effects of Synalar

Local side effects

Skin thinning (cutaneous atrophy) is the most important side effect of potent topical corticosteroids.

It occurs because corticosteroids inhibit collagen synthesis in dermal fibroblasts and reduce epidermal cell turnover.

Signs include visible blood vessels (telangiectasia), stretch marks (striae), easy bruising (purpura), and a shiny, translucent appearance.

These changes are more likely with prolonged use, use under occlusion, and use on thin-skinned areas. Striae are usually permanent once formed.

Skin thinning is generally reversible if the corticosteroid is stopped early enough.

Burning, stinging, or itching at the application site may occur, particularly on first application to broken or inflamed skin. This usually settles quickly and does not indicate allergy.

Perioral dermatitis is a papulopustular eruption around the mouth that can be triggered or worsened by topical corticosteroid use on the face.

It typically presents as small red bumps and scaling around the lips, chin, and nasolabial folds.

Treatment requires stopping the corticosteroid (which may initially cause a rebound flare) and using oral or topical antibiotics.

Steroid rosacea and acne-like eruptions may develop with prolonged facial use. Masking or worsening of skin infections (bacterial, fungal, viral) can occur because corticosteroids suppress the local immune response.

Systemic side effects

Systemic absorption is generally low with short treatment courses on limited body areas.

However, significant systemic absorption can occur with prolonged use, use over large body surface areas, use under occlusion, use on broken skin, and use in children (who have a higher body surface area to weight ratio).

Potential systemic effects include hypothalamic-pituitary-adrenal (HPA) axis suppression, Cushing syndrome features (moon face, weight gain, striae), hyperglycaemia, osteoporosis, and growth retardation in children.

When to seek medical advice

Consult your GP or pharmacist if your skin condition worsens during treatment, if you notice signs of skin infection, if you develop unusual skin changes, or if you experience symptoms that might suggest systemic absorption (unusual fatigue, weight gain, mood changes).

Report suspected adverse reactions to the MHRA at yellowcard.mhra.gov.uk .

Warnings and precautions

Contraindications

Synalar must not be used on untreated bacterial, fungal, or viral skin infections, including impetigo, ringworm (tinea), athlete's foot, herpes simplex (cold sores), chickenpox, and shingles.

It must not be used on acne vulgaris, rosacea, or perioral dermatitis. It should not be used on ulcerated skin or wounds.

Face, flexures, and genital areas

These areas have thin skin and are at highest risk of corticosteroid side effects.

Use Synalar on the face only if specifically directed by a dermatologist, and limit treatment to 5 days.

For the flexures (groin, axillae, antecubital fossae, popliteal fossae) and genital areas, use the minimum effective amount for the shortest duration.

A milder corticosteroid is usually more appropriate for these sites.

Children

Children are more susceptible to the local and systemic side effects of topical corticosteroids.

The NICE guideline on atopic eczema in children (CG57) recommends that potent topical corticosteroids should be used in children only under specialist guidance.

The treatment area, duration, and amount should be carefully controlled.

Parents and carers should be educated about the fingertip unit method and the importance of not exceeding recommended courses.

Topical corticosteroid withdrawal

The MHRA issued a Drug Safety Update in 2021 regarding topical corticosteroid withdrawal reactions.

Prolonged, frequent use of potent or very potent topical corticosteroids can lead to a dependency-like state.

If the corticosteroid is stopped abruptly, a withdrawal reaction may occur, characterised by intense redness, burning, stinging, and skin peeling that may be more widespread than the original treated area.

If you have been using Synalar regularly for a prolonged period, discuss a gradual reduction plan with your prescriber rather than stopping suddenly.

Pregnancy and breastfeeding

Avoid prolonged or extensive use of potent topical corticosteroids during pregnancy, particularly during the first trimester.

Short courses applied to limited body areas may be used if the prescriber considers the benefit outweighs the potential risk.

If used while breastfeeding, do not apply Synalar to the breasts immediately before nursing.

How to get Synalar in the UK

Synalar is available on NHS prescription from your GP or an authorised online prescriber registered with the General Pharmaceutical Council (GPhC).

The standard NHS prescription charge in England is 9.90 pounds per item; prescriptions are free in Scotland, Wales, and Northern Ireland.

Prepayment certificates (PPC) are available for patients who need multiple prescription items regularly.

A 3-month PPC currently costs 31.25 pounds and a 12-month PPC costs 111.60 pounds, saving money for those who require four or more prescriptions in 3 months.

Sources

• Synalar Cream, Summary of Product Characteristics (EMC)
• Fluocinolone acetonide, British National Formulary (BNF)
• Eczema, atopic, NICE CKS
• Corticosteroids, topical, NICE CKS
• Atopic eczema, NHS
• MHRA Yellow Card Scheme