What is Ketoconazole?
Ketoconazole is an antifungal medication primarily used in the treatment of fungal and yeast infections such as ringworm, athlete’s foot, seborrheic dermatitis and dandruff. Apologies to those eating breakfast!
It was discovered in 1976 and first marketed as an oral antifungal drug in 1981. It’s also now available in topical preparations which include creams, gels , foams, and, most commonly, shampoos. We’ll stick to a discussion of ketoconazole shampoo for hair loss for the purposes of this article.
As with a number of other hair loss treatments, including FDA approved medications such as minoxidil (Rogaine), ketoconazole was originally developed to treat other conditions. It’s potential as a hair loss treatment wasn’t discovered until later.
How Does Ketoconazole Work?
As is common with hair loss treatments, there are several theories.
Let’s start with a view from a heavy hitter – the American Hair Loss Association (AHLA). They note that, apart from its anti-fungal properties, ketoconazole also has anti-androgenic effects. That is, when ingested orally, it’s known to inhibit the binding of androgens to receptors in the body. This includes the binding of DHT to hair-follicle receptors. (DHT is the main protagonist in the leading causal theory of hair loss. So it’s kind of a big deal.)
The AHLA further note that ketoconazole may have a similar effect when applied topically to the scalp. Such as in a ketoconazole based shampoo, for instance.
In addition to its anti-androgenic effects, researchers cite two other potential modes of action: sebum reduction and anti-inflammation.
In the case of sebum reduction, ketoconazole may reduce the activity of the sebaceous glands. Thus reducing sebum production. Since sebaceous glands are attached to hair follicles, overactive glands may clog the hair follicles with excess sebum and disrupt the normal process of hair growth.
Ketoconazole is also said to be instrumental in reducing inflammation. People experiencing androgenetic alopecia (pattern baldness) typically also experience varying degrees of inflammation of the scalp.
You can read more in my previous article on Nizoral here.
How Effective Is Ketoconazole Shampoo for Hair Loss?
Your guess may be as good as mine. However, there are several sign posts worth paying attention to:
- Clinical studies
- Anecdotal evidence: Ketoconazole is almost universally touted one of ‘The Big Three’ hair loss treatments. You may have heard of the other two: finasteride (Propecia) and minoxidil (Rogaine). It’s also highly regarded across popular hair loss forums.
- Personal experience: I’ve tried two of the ketoconazole shampoos listed in the ‘Cost and Availability’ section below. One produced mildly positive results. The other, significantly positive (more on this later).
Which is why it’s worth taking a closer look at the studies. (That, and medical journals are really cool).
Journal of Dermatology (2005)
A 2005 study examined the effects of 2% ketoconazole on shaved mice. One group received a topically applied placebo and the other a 2% ketoconazole solution. The solutions were administered over a three week period, once daily. The 2% ketoconazole was shown to have clearly stimulated hair regrowth.
However, shaved mice are not the same as barren human heads. Moreover, three weeks is not a sufficient period in which to prove efficacy – particularly given length of hair growth cycles. A better conclusion from the study may simply be that ketoconazole speeds up hair regrowth, rather than treating hair loss.
Journal of Dermatology (2002)
An earlier open, randomised clinical trial, published in the same journal, compared several different combinations of drugs for treating pattern baldness.
One hundred men suffering from pattern baldness (androgenetic alopecia) were separated into four groups and administered discrete treatments over a one year period:
- Group I – 1 mg per day of oral finasteride
- Group II – 1 mg/day oral finasteride + 2% topical minoxidil
- Group III – 2% topical minoxidil
- Group IV – 1 mg/day oral finasteride + 2% ketoconazole shampoo
Results showed that all 4 groups experienced significant hair growth, although the best results were seen in patients in Group II followed by Group IV, I and III.
Medical Hypotheses (2004)
The effectiveness of the ketoconazole finasteride combination (Group IV from above) was further demonstrated in a 2004 study. In short, ketaconazole was shown to potentiate finasteride’s primary mode of action: inhibition of DHT.
In the earliest of these studies a 2% ketoconazole shampoo and a non-medicated placebo shampoo, mixed with or without 2% minoxidil, were trialled.
Results indicated that both 2% ketoconazole and 2% minoxidil were similarly effective in increasing hair density, as well as the size and proportion of hair follicles. It was also noted, however, that “[t]he clinical significance of the results awaits further controlled study in a larger group of subjects”.
The above studies, whilst inconclusive, suggest that ketoconazole provides support for hair loss – in addition to its proven ability to treat fungal and yeast infections. Indeed, it may be particularly effective in conjunction with other primary treatments such as minoxidil (Roganie) and finasteride (Propecia).
Guidelines for Effective Use
The guidelines for effective application of a ketoconazole shampoo for hair loss are broadly similar to those of other medicated shampoos. Use as directed on the label, avoid skipping applications, and let the shampoo sit on your scalp for 3 – 5 minutes to give it time to work.
Many commentators will tell you that a ketoconazole shampoo should not be used as a replacement for your daily shampoo. In my personal opinion, this depends on the particular brand (but that is a discussion for a future article).
The amount of product needed, as well as frequency of use, may vary from one individual to another. I normally start following the directions as written, until I’ve achieved the benefits I’m looking for. After that I reduce the dosage to the point where I maintain what’s been achieved. This is a trial and error exercise, so unfortunately can’t provide any hard and fast rules as to how to go about this. The key, really, is to closely monitor and adjust as required.
Potential Side Effects
According to the American Hair Loss Association, there are no significant side effects relating to topical application of ketoconazole shampoo for hair loss. In general terms, the risk of systemic toxicity from ketoconazole (see my article on systemic effects here) is low when applied to the scalp. The same cannot be said if ingested orally. Luckily, ketoconazole shampoo doesn’t taste good!
That said, the more common side effects can include mild irritation or stinging. These can be caused by ketoconazole or one of the inactive ingredients. If this occurs try using the shampoo less frequently, or switch to another brand. According to the Mayo clinic, however, the above symptoms are likely to disappear after multiple uses of any given product
For further information on potential side effects go here. Note that these may apply in particular to those products containing 2% ketoconazole. Perhaps for this reason, in the US at least, shampoos containing 2% ketoconazole are only available on prescription.
Best Suited For
Men or women suffering from pattern baldness (androgenetic alopecia), who aren’t averse to applying medicated products. Those looking for a natural solution should look elsewhere (there are several natural alternatives discussed elsewhere on this site, e.g. Revivogen).
- Relatively inexpensive, depending on which brand you buy
- It can be used in conjunction with other topical treatments (e.g. minoxidil)
- Easy to fit into your existing routine
- Unlike some more powerful anti-androgens, can be used by both men and women (check if pregnant)
- Relatively expensive, depending on which brand you buy
- Likely not a primary hair loss treatment
- Assuming it works for you, you need to keep using the product for as long as you wish to control your hair loss or regrow hair
Cost and Availability
Once upon a time Nizoral was the only ketoconazole shampoo available on the market. Times have changed. There are several brands of ketoconazole shampoo for hair loss now available, the most common of which are listed below (I’ll compare the leading brands in a future article).
Of these, I’ve tried Nizoral (mildly positive results) and am currently using the Regenepure DR shampoo (with surprisingly good results).
In the US, only 1% ketoconazole shampoo is available over the counter (OTC). In countries such as the UK, or much of Europe, both 1 and 2% versions can be purchased without prescription.
Below are the non-prescription brands of ketoconazole shampoo available.
|Nizoral Shampoo||USD 12 – 18||Purchase from manufacturer recommended outlet|
|Regenepure DR (‘Doctor Recommended’)||USD 25||Purchase from Manufacturer|
|DS Laboratories Revita Shampoo||USD 30||Purchase from Manufacturer|
|Perfect Hair Anti Loss Shampoo||USD 20||Unable to locate manufacturer as at time of writing|
|Lipogaine Big 3 Premium Hair Loss Prevention Shampoo||USD 25||Purchase from Manufacturer|
|Boots Anti Dandruff Shampoo (UK only)||GBP 9||Purchase from Manufacturer|
Other, prescription-only, brands are also available. These include, Dandrazol anti-dandruff shampoo and Ketopine 2% shampoo.
Hair Today There Tomorrow View
Whilst Nizoral (ketoconazole) is an FDA approved treatment for individuals with conditions such as dandruff and seborrheic dermatitis, the same cannot be said for its use in treating hair loss.
Although the research conducted to date is positive, further research is needed to support ketoconazole as a clinically proven treatment for hair loss. Ideally, this would be conducted using randomized, double-blind studies over a prolonged period of time. However, these are expensive and take, well, time.
Of the research that has been conducted, it’s also worth noting that effectiveness of ketoconazole shampoo for hair loss seems to compare favourably with 2% Minoxidil only (Rogaine). Generally speaking, 2% minoxidil produces significantly less positive results than the 5% version and so provides a lower base for comparison. Personally, I use a 5% minoxidil product in conjunction with a ketoconazole shampoo.
Which leads me to the significant body of anecdotal evidence which clearly support effectiveness of a ketoconazole shampoo for hair loss. Particularly when used in conjunction with Minoxidil (Rogaine) and / or finasteride (Propecia). Ultimately, however, you will need to be the judge.
In my case, Nizoral didn’t prove to be particularly effective when I used it in the earlier stages of my hair loss journey (see my related article on Nizoral here). I’ve learnt a lot since then, so my modest success may have been due to the way I applied it.
Regenepure DR, on the other hand, did work (see that article here). The difference may simply be that I was a more informed consumer by the time I started this treatment. Whatever the case, I’ll continue with Regenepure for now.
Before I leave you I’ll sign off with the same advice that you’ll likely read on other trusted sites. In short, it’s likely that a ketoconazole shampoo is not a primary hair loss treatment and should be used in conjunction with other, proven, treatments. If you’re willing to experiment, however, I suggest you begin with a milder form of treatment, such as a ketoconazole shampoo, before trying additional options. It may prove sufficient in your particular case. If you can avoid adding chemicals to your scalp, as well as spend less on products, it’s probably an approach worth experimenting with.