True, it doesn’t work for everyone. No active ingredient does. But if someone is newly diagnosed with seb derm, there’s a reason so many doctors and dermatologists to a 2% ketoconazole shampoo. It’s the most effective active ingredient out there.
It worked for me too. After years of not even knowing what I had, all it took was a diagnosis and a few washes with ketoconazole and I have been set up for almost 20 years.
At the end of this article, we’ll look at our favorite ketoconazole shampoos. But before I do that, it’s important to look at what ketoconazole is, any risks with using it, and how it helps your condition before recommending the best shampoos on the market today.
Ketoconazole is an imidazole derivative, broad-spectrum antifungal. In the UK, a 2% shampoo is available to buy from pharmacies for treating seborrheic dermatitis or dandruff as several brands (Ketopine, Nizoral). If your symptoms are severe, your doctor might want to prescribe the shampoo to monitor the condition.
When ketoconazole is used as a shampoo it’s not absorbed into the bloodstream, and so the antifungal effects are localized to the scalp . It works by inhibiting enzymes necessary for a fungus to synthesize steroids in the cell membrane. This leads to the cells becoming ‘leaky’ – unable to correctly regulate electrolytes – causing them to breakdown.
For scalp conditions associated with an underlying fungal infection, ketoconazole shampoos should generally be applied once or twice a week . The shampoo should be massaged over the entire scalp and left for 3-5 minutes before thoroughly rinsing – although products can vary, so you should always read the label!
Who Invented It?
The oral formulation of ketoconazole was developed by Janssen Pharmaceuticals in Belgium – the company behind other well-known drugs such as Imodium and Daktarin!
Ketoconazole was first discovered in 1976 and for the first 10 years, it was applied orally. Relatively soon after it was relatively quickly replaced with less toxic alternatives that didn’t have as many drawbacks :
* Absorption varied by individual
* It couldn’t penetrate the brain for more serious infections
* It resulted in gastrointestinal side effects, and liver toxicity
* Several important drug interactions were discovered
In 2013 due to the risk of liver toxicity, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) formally recommended suspending the license for oral ketoconazole, advising doctors to discuss alternatives with patients . This recommendation specifically excluded topical formulations (e.g. shampoos, creams), because they are not readily absorbed into the bloodstream.
Ketoconazole shampoos have been shown to be effective against a range of fungus and yeast species. These are known to cause several scalp conditions, and so your doctor may prescribe ketoconazole shampoo if your symptoms are consistent with an underlying fungal infection – without needing to send a sample for microbiological testing. Common species susceptible to ketoconazole are summarized below :
P. ovale (Malassezia)
How Effective Is Ketoconazole At Treating Dandruff
Ketoconazole shampoos are currently one of the first-line treatments in seborrheic dermatitis. The treatment has been around for a long time and has shown to be effective in pivotal clinical trials. A summary of the role of ketoconazole shampoos in common scalp conditions is described below.
Seborrheic dermatitis is thought to be caused by excess Malassezia, which results in chronic inflammation. A 2015 Cochrane Review identified 51 studies covering over 9000 participants and found those using a ketoconazole shampoo were 31% less likely to have recurrent symptoms within four weeks compared to placebo . The analysis also found that ketoconazole was more effective than ciclopirox, and as effective as steroids – with significantly less adverse effects.
Scalp psoriasis is an inflammatory condition, not typically associated with an underlying fungal infection. The first-line treatment for scalp psoriasis is a short course of corticosteroids. In the 1980s several studies showed that oral ketoconazole could be of some benefit in treating the condition, but the significant adverse effect profile and efficacy of corticosteroids prevented further research .
The 1-percent ketoconazole products such as Nizoral are available over the counter. The stronger two-percent shampoo must be prescribed by a doctor in the USA. However, in countries like the UK or much of Europe, it is available OTC.
Personally, I think it’s about time the US followed suit…
Ketoconazole Product Brand Names
Ketoconazole is sold under a number of brand names including:
What Are The Risks With Using It?
When used as a shampoo ketoconazole is very well tolerated, not associated with the harmful effects of the oral formulation. In a review of 22 clinical trials covering over 2800 participants, no adverse effects had an incidence of over 1% . The most common reactions occurred in 1 in every 100-1000 people:
Regenure DR Hair and Scalp Treatment is a 1% Ketoconazole formulation shampoo combined with Salicylic Acid. The company ave been particularly clever with their formulation and marketing – positioning the shampoo as a gentler alternative to Nizoral. The company have largely achieved that too. Adding Salicylic Acid to get rid of the dandruff and ketoconazole to remove the dandruff is an inspired combination too.
That said, it’s still a 1% ketoconazole shampoo. Given the choice I’d choose 2% every time, but this would require a prescription in Regenpures largest market – the USA.
Boots are a UK retail pharmacist similar to Walgreens or CVS in the USA. Walgreens and Boots are actually strategic partners (whatever that actually means). Boots have developed their own 2% Ketoconazole shampoo which is a cheaper alternative to Nizoral. Although it does contain a number of harsh ingredients, it’s definitely worth a look if you want a cheaper alternative. Expect a review in the coming months.
If not, please let us know in the comments below which shampoos you’d like us to take a look at!
 Faergemann, J., Borgers, M., & Degreef, H. (2007). A new ketoconazole topical gel formulation in seborrhoeic dermatitis: an updated review of the mechanism. Expert opinion on Pharmacotherapy, 8(9), 1365-1371.
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