Ketoconazole shampoos have become an increasingly popular way to treat hair loss, but is there actually any evidence to show they can regrow your hair?
Could they even make hair loss worse over the long-term?
This in-depth guide will take a close look at ketoconazole: its uses, how it works, and the relevant research studies.
I should, however, disclose that I’ve never personally used ketoconazole. I actually think it’s a bad idea to use any kind of pharmaceutical chemicals on your head in any form. But many people do use ketoconazole.
While the results are certainly encouraging (as we’ll see later), I believe that all-natural is the way to go if you want to treat the root cause of your hair loss.
Many over-the-counter ‘hair loss products’ just mask the symptoms, while also causing further harm down the road, because they don’t attack the root cause.
In fact, a much better option for getting the benefits of ketoconazole (after 4 years researching and experimenting), without any side effects, is to simply use 4 teaspoons of apple cider vinegar to wash your hair, once or twice per week.
However, if you do decide ketoconazole is right for you, I’ll also offer some tips on how to use it most effectively.
What Is Ketoconazole?
An antifungal drug used primarily in the treatment of fungal infections, ketoconazole was discovered in 1976 by Janssen Pharmaceutica in Belgium.
There are a few brand names under which it is sold, such as Extina, Xolegel, and Ketoderm. However, the most popular brand name is Nizoral. This is one of the most common anti-dandruff medications on the market today.
In this article we will be looking primarily at the shampoo version, but ketoconazole is available in many forms. These include a gel, foam, cream, and even tablets for oral consumption (more on these later).
How It Works
The main mechanism by which ketoconazole operates is through its killing of fungi and yeasts. The drug stops the production of an organic molecule commonly found in fungus and yeast – ergosterol – and this interferes with the cell membrane of both organisms.
With the cell membranes compromised, the organisms are no longer able to reproduce.
Ketoconazole is what you call a “broad spectrum” drug. This means it is effective against many species of micro-organisms.
These include not only the fungus responsible for most cases of dandruff (discussed below) but many other, often more severe, fungal infections of the scalp.
Ketoconazole can also be taken to trust candidiasis (thrush).
Is Ketoconazole a Hair Loss Treatment?
It is important to stress at the outset that ketoconazole is sold as an over-the-counter medicated shampoo for the treatment of dandruff and certain fungal infections. Depending on its form (topical or oral) ketoconazole can be used to treat fungal infections in most parts of the body.
Male pattern hair loss is not a fungal condition. So neither the manufacturer markets Nizoral shampoo as a treatment for pattern hair loss, nor has the FDA approved it for this indication.
Accordingly, you won’t find hair loss mentioned anywhere in the package insert of the product.
Having said that, in recent years ketoconazole shampoos have gained somewhat of a following among certain segments of the hair loss community.
Supporters of ketoconazole often reference a handful of research studies conducted some years ago. The authors of those studies looked at ketoconazole shampoos outside of their intended use, and in particular as a treatment against male pattern baldness. We will review this research shortly.
But let’s first have a look at the well-documented antifungal, antidandruff properties of ketoconazole. This will give you a better idea of how this medication works.
In a subsequent section we will look at the limited data there is with regards to its action as a hair loss treatment.
Ketoconazole, dandruff and seborrheic dermatitis
What’s the #1 scalp condition affecting millions of people worldwide each year?
You’ve guessed it – dandruff!
This condition – characterized by itching and large, white flakes – is more than just a case of dry scalp.
All healthy people lose skin cells on their scalp and the rest of their body all the time, but these are normally not visible.
In dandruff this changes.
The white, ugly, crusty flakes we see in dandruff are actually a cluster of dead skin cells that for one reason or another retained a high degree of cohesion and detached as one piece from the scalp.
This is a condition believed to have many causes, including airborne chemicals and even stress. But in most cases, the chief culprit is a fungus by the name of Malassezia.
This is a family of fungi normally found in the scalp of healthy people. But in dandruff, Malassezia multiplies out of control, and it basically takes over the scalp.
The exact mechanism by which Malassezia causes dandruff is not clear.
Be that as it may, the evidence implicating Malassezia in the pathogenesis of dandruff is strong. For example, a 2014 study found Malassezzia to be present in the scalp of 84% of a sample of dandruff patients. This was in contrast to healthy people, where Malassezia was only found in 30%.
And, whatever the mechanism is, the fact is that getting rid of Malassezia often helps get rid of the symptoms of dandruff.
And ketoconazole is very good at doing this.
With a powerful anti-fungal like ketoconazole, the yeast is no longer able to reproduce or survive.
This leads to less scaling, and reduction of the other bothersome symptoms, like itching and redness.
A related condition to dandruff is seborrheic dermatitis (SD).
Like dandruff, SD is characterized by inflammation, itching, scaling, redness, flaking (yellowish or white), and overproduction of grease.
But unlike dandruff, it can also occur in areas outside the scalp. These include the ears, eyelids, neck, upper back, chest, and armpits.
While there’s no exact cause pinpointed, it’s believed that SD is dependent on a number of factors. These include age, gender, and immune system health. And, as with dandruff, Malassezia is also thought to play a role.
Unsurprisingly, then, given what we have discussed so far, SD often responds very well to treatment with ketoconazole. When the SD affects the scalp the shampoo version can be used, but for SD of the face or other areas of the body, the cream is applied.
What about Ketoconazole and Hair Loss?
So what about hair loss?
As mentioned above, ketoconazole is not licenced or sold as an anti-hair loss drug.
Which begs the question: why do some balding men use it for this purpose?
Let’s have a look at the available evidence.
A 2005 Japanese study was one of the first to directly study ketoconazole’s role in hair growth. This was performed on mice, and the results were quite promising.
A similar study was performed in 2014 – again on mice – but this time it compared ketoconazole to minoxidil and minoxidil with tretinoin (an acne treatment).
The mice were first split into four groups (of five mice), and their dorsal hairs were shaved. A stain was then applied so researchers could better track the growth of new, non-dyed hairs.
The groups were split as follows:
Group I was the control, and it received 1 mL of 95% ethanol once daily for 6 days/week for 3 weeks.
Group II received Ketoconazole solution 2%, 0.1 mL once daily for 3 weeks.
Group III received Minoxidil solution 5%, 0.1 mL once daily for 3 weeks.
Group IV received equal amounts of Minoxidil solution 5% + Tretinoin 0.1%, 0.1 mL once daily for 3 weeks.
As results were compared after three weeks, it was obvious that ketoconazole, minoxidil, and minoxidil with tretinoin were all superior to the placebo group.
This was shown when comparing both the number of hair follicles, as well as the mean diameter of hair follicles.
Of course, these results were also visually significant, as shown by the side-by-side comparison image below.
On the left is the control group, showing insignificant growth (as noted by the presence of dye). On the right is the ketoconazole treatment group, showing significant growth in just three weeks’ time.
As noted by the researchers, the positive effects of ketoconazole likely “stem from its antiandrogenic properties”.
Let’s dig into this statement a bit deeper.
When it comes to battling male pattern baldness (or androgenetic alopecia – AGA) one of the best ways to do so is to target and remove DHT from the scalp.
DHT (dihydrotestosterone), as you might know, is one of the four androgens, or male hormones. It is also the primary molecule implicated in male pattern baldness.
This is because those with AGA are sensitive to DHT (even normal levels), and this can cause irritation and miniaturization of the hair follicle.
As the follicle miniaturizes, the hair growth cycle slows and, eventually, ceases completely.
Medications like finasteride work by block DHT all over the body, but blocking DHT in the scalp also works, probably just as well.
It turns out ketoconazole may also play a role in inhibiting the synthesis of DHT when applied directly on the scalp.
Studies with prostate cancer patients have also confirmed the potent antiandrogenic properties of ketoconazole. These studies find that when taken orally, ketoconazole brings about a significant reduction of testosterone levels.
So how does all this translate into balding men?
One of the first studies on the topic was published more than 20 years ago.
The study recruited 39 men with androgenetic alopecia, or which 27 used Nizoral shampoo for a 21-month period. The other 12 men used regular unmedicated shampoo.
At the end of 21 months, the men in the Nizoral group showed improvements in the proportion of anagen hairs (i.e. hairs in the growth phase of their cycle) as well as in the average diameter of their hair shaft.
This combination of more growing hairs that were also thicker led to fuller hair after 6 months on the treatment. The gains continued, until they stabilized after 15 months.
The men who were using the unmedicated shampoo, on the other hand, continued on the slow but steady decline that is typical of AGA.
The results of this first study spurred the researchers to conduct a second study (both of these studies were reported in the same paper).
In this second study, two groups of men were studied. There were 4 men in each group. One group used Nizoral shampoo, and the other group applied daily topical minoxidil (while also using regular, unmedicated shampoo).
After 6 months, both groups of men showed an increase in hair density, which was 18% in the ketoconazole group and 11% in the minoxidil group. The median hair shaft diameter in both groups increased by 7%.
The authors concluded that ketoconazole shampoo results in an unequivocal increase in hair density, size and proportion of anagen hairs.
There have been more recent studies on the topic, including those performed in 2002, 2006, and 2011.
While each of these studies did see hair growth in most of its subjects, there were some limitations. These include sample size and consistency of use among test subjects.
How to Use Ketoconazole Most Effectively
If you decide to add ketoconazole to your hair loss treatment plan, there are a number of other methods which you can use alongside it.
These methods are natural, and they can further promote hair growth.
As the enzyme necessary to convert testosterone to DHT, the inhibition of 5-alpha-reductase (5AR) can go a long way in preventing male-pattern hair loss.
This can be done in two ways: through topical application of proven 5-alpha-reductase inhibitors, or through oral ingestion of similarly inhibiting substances.
As 5AR converts testosterone to DHT, inhibition of this enzyme can prevent male-pattern hair loss.
Costs and Availability
While tablets and creams are the typical prescription method, there are a few over-the-counter formulas available for purchase. These consist of shampoos (both 1% and 2%), as well as ointments.
As a popular over-the-counter fungal treatment, there are a number of brands to choose from. The most common brand is Nizoral, and an 8-oz bottle can typically be purchased for around $15.
While this may seem a bit pricey, the product is only used a few times per week in the beginning of treatment (afterwards, its use is intermittent).
This means that the product will last a reasonable length of time.
But more important than the costs are the potential side effects of ketoconazole.
Ketoconazole Side Effects
As with any medication, ketoconazole has a few possible side effects that may interfere with its continued use or make continuation altogether impossible.
In 2013 the FDA issued a warning and limited the usage of ketoconazole tablets. The FDA warned of potentially fatal liver problems and serious adrenal gland problems.
The agency also warned of potentially very serious drug interactions.
The label of the drug was changed, and the FDA recommended the drug no longer be a first-line treatment for fungal infections.
As mentioned, these warnings apply to the oral version of the drug, not the shampoo.
But it is still worth asking yourself if you want to be applying such a strong chemical on your scalp.
What about the shampoo version – what are the most common side effects?
According to the Mayo Clinic, the most common of these are itching, stinging, burning or irritation. On rare occasions the shampoo may cause hair loss.
In the event side effects occur, they may subside as your body adjusts to the medication.
If you find these side effects are too strong and cause distress, discontinue treatment and consult with your doctor.
But as with any medicated product, it’s a good idea to consult with your physician prior to usage anyway.
This is especially true if you’re currently on any prescription medications, or if you have any chronic health conditions.
How to Add Ketoconazole to Your Hair Care Routine
As a readily available shampoo, ketoconazole products can be easily added into your regular hair care routine.
As a medicated product, it’s recommended that you follow a consistent regimen for 6-8 weeks. This means using the shampoo every 2-4 days for the mentioned length of time, and then using periodically (1-2 times per month) for continued benefits.
How to Use Ketoconazole Shampoo
If you decide to use ketoconazole, you’ll want to ensure you’re using it most effectively.
Let’s take a closer look at the instructions:
- Wet the area of the scalp affected by hair loss.
- Apply the ketoconazole shampoo directly to the area affected by hair loss, and a large radius around it.
- Massage the shampoo into the affected area for one minute, allowing it to fully lather.
- Let sit for 5 minutes.
- Rinse with lukewarm/cool water.
Practically, it will be much easier if you start your shower by applying the ketoconazole. You can then wash the rest of your body while you let the ketoconazole act on your hair.
While ketoconazole shampoo can be applied to the entire scalp, you want to ensure you pay particular attention to the area of hair loss. This means focusing the majority of your massaging efforts there, and using a circular motion while doing so.
By allowing it to sit, you also ensure the ingredients penetrate the scalp and hair follicles.
But you may be wondering:
“Why must I rinse with lukewarm/cool water?”
The fact is, hot water causes damage to the scalp and hair follicles. It leads to dryness, inflammation, and irritation and it should be avoided whenever possible.
By rinsing your scalp with lukewarm/cool water, you prevent any irritation from occurring.
Cold water rinses have other benefits, too!
Namely, increased circulation which is great for oxygen/nutrient delivery and waste removal.
Are There Natural Alternatives to Ketoconazole?
Actually, the best way to treat dandruff and seborrheic dermatitis long term is with improvements to your diet, as well as avoiding hot showers!
The use of store-bought products is not something which I recommend.
This is because the majority are full of chemicals which will only lead to more scalp and hair follicle damage in the long run.
Further, the use of homemade shampoos can be tailored to fit your exact needs.
So, what do I recommend instead?
- Apple Cider Vinegar (1 cup)
- Water (1 cup)
- Rosemary (1 bunch)
- Jojoba Oil (20 drops)
- Peppermint Essential Oil (10 drops)
Bring water to a boil, then add the rosemary and remove from heat. Allow the tea to cool.
While the tea cools, combine the apple cider vinegar, jojoba oil, and peppermint essential oil in the container of your choice. Drain the rosemary tea, adding the tea water to the combined ingredients and discarding of the rosemary.
To use, lather onto your hair and massage deep into your scalp. Allow to sit for 1-3 minutes, and then rinse thoroughly with cool water.
When treating dandruff and similar scalp conditions that lead to inflammation, irritation, and scaling, you want to focus on hydration while also soothing the scalp and bringing it back to its natural pH balance.
This recipe does just that, combining the soothing effects of rosemary and peppermint oil and the hydrating effects of jojoba oil.
In addition, the apple cider vinegar gently cleanses the scalp and hair, and the peppermint oil also brings the scalp’s pH back to its natural balance.
An Easier Solution
The benefits of preservative-free shampoos cannot be overstated. But, not everyone has the time or willingness to make their own at home.
So, what now?
That’s where our line of natural products comes in!
Using the Hairguard Caffeine Shampoo, you can cleanse and reinvigorate your scalp. There’s no harsh chemicals or preservatives – just all-natural ingredients that stimulate the hair follicles and help fight hair loss.
And with this shampoo, you never have to mix your own products again! This is a time (and money) saver for many, and it’s something you should consider if you’re having trouble saying goodbye to off-the-shelf products.
Why You Should Stop Using Chemical Shampoos Altogether
I have found that to reverse hair loss, the health of your scalp is very, very important. In fact, it’s hard to overstate just how important scalp health is for hair regrowth.
Just think of a plant growing in a garden: the top soil is probably the most important factor of whether the plant thrives or dies (given it has sunlight and air.)
Although ketoconazole shampoo may initially feel like it is helping, over time the scalp of your health might get worse because of the chemicals.
If you have scalp fungus, this really isn’t the way to get rid of it.
Let me show you what to do instead.
You must actually change your diet. Doing so will make it impossible for fungi to grow out of control in the first place, and might also stop your dandruff.
Firstly, get rid of yeasty foods such as bread and beer. Cut down your intake of harmful foods such as sugary drinks, refined grains, dairy products and refined oils.
Increase your intake of vegetable juices, herbs, spices, and fruits.
I also recommend adding more healthy fats to your diet.
- Coconut oil
- Brazil nuts
- Cashew nuts
- Cold water fish
- Bone broth
Try adding in these foods to your diet and removing the ones I mentioned earlier. In a few weeks’ time you’ll have a much healthier scalp, and as a result, much healthier hair.
There’s no doubt that ketoconazole can help significantly in the treatment of SD and dandruff.
The jury is still out on its hair-growth properties, though there is some compelling evidence in this regard.
This doesn’t mean, however, that it’s the best option available to you.
Remember that dandruff and hair loss are conditions that best resolved internally. Such methods will lead to longer-term results, and will also have a number of other positive health effects.
Such a task isn’t always easily undertaken, especially when we’ve been conditioned to survive on the typical Western diet of grains, processed sugar and lots of yeasty foods.
*This article was reviewed by Dr. Debra Rose Wilson.