Ketoconazole: uses, benefits, and side effects

Ketoconazole is a medication used most commonly to treat fungal infections. But since it first hit the market in the 1980s, scientists have discovered additional uses for it.

Because of the way ketoconazole works, researchers believe it may be able to play a role in halting hair loss, though more research is needed to back that claim up. Let’s take a closer look at ketoconazole and how it’s used.

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Ketoconazole is a medication commonly used to treat fungal infections like ringworm, jock itch, athlete's foot, and dandruff. You can get topical ketoconazole as a cream, shampoo, gel, or aerosol foam (Sinawe, 2021).

For serious infections that have reached the bloodstream, oral ketoconazole tablets can be prescribed. Topical prescriptions are usually 2% concentration in strength. There’s also a 1% ketoconazole shampoo that’s available over-the-counter (OTC) without a prescription. 

Right now, ketoconazole is only approved to treat fungal infections and skin conditions, but it's also used off-label for hair loss. 

Ketoconazole is sometimes used to treat androgenic alopecia––a type of hair loss linked to hormones. Androgenic alopecia is sometimes referred to as male or female pattern baldness.

Scientists know that one of the central causes of hair loss is dihydrotestosterone (DHT), a potent form of testosterone that plays an important role in the development of alopecia. Other hair loss treatments, like finasteride (brand name Propecia) work by blocking DHT.

Research has shown that ketoconazole can block the conversion of testosterone to DHT, which has piqued interest in testing the antifungal for hair loss. 

While some studies show promising results, they aren’t as dramatic as those achieved with finasteride or other medications like minoxidil (brand name Rogaine) (Fields, 2020).

That doesn't mean that ketoconazole doesn't help with hair loss, it just means there are other proven options you can try first. You can also speak with a healthcare provider about adding a ketoconazole shampoo to your regimen. 

There are different forms of topical ketoconazole, each with its own uses and directions. Your dosage and treatment duration will vary based on your condition.

Below are FDA-approved uses and typical treatment directions for each product. Always use ketoconazole as directed by your provider. For example, if your recommended treatment duration is 2–4 weeks, continue to use the medication for that time even if your condition improves.

Ketoconazole 2% cream

Ketoconazole cream treats fungal infections all over the surface of your body, including your feet and genital area. The cream should be applied to the affected area of your skin once a day. Infections on most parts of your body, including your face, torso, and genital usually require two weeks of treatment. Foot infections typically require six weeks of treatment (UpToDate, n.d.). 

The cream can also be used for seborrheic dermatitis—a form of eczema that affects oily skin areas like your scalp, face, and back. The typical dose for this is one application to the affected area, two times a day for four weeks.  

Use your finger to apply cream directly to the affected area of your skin. Make sure the cream covers the entire area, as well as the surrounding skin (UpToDate, n.d.). 

Ketoconazole 2% shampoo

You might associate shampoo with hair and scalp care. Yet, the ketoconazole shampoo treats a type of fungal infection that causes discolored patches on your skin, called tinea versicolor. These infections are usually located on your torso, but can also be found on your neck, arms, and upper thigh. Usually one treatment with the shampoo is enough to treat this infection. 

Make sure your skin is damp before using the shampoo. Apply it to the affected area and a little bit of the skin surrounding it. Work the shampoo into a lather and leave it in for 5 minutes. After the time is up, rinse out the shampoo thoroughly with water (UpToDate, n.d.).

Ketoconazole 2% foam

This foam is FDA-approved to treat seborrheic dermatitis in people ages 12 and older with healthy immune systems. The typical dose is one application to the affected area twice a day for four weeks. 

Applying the foam product can be a little tricky. Don’t dispense it directly onto your hand as it will melt into your skin. Instead, dispense the foam into the cap (most foams come with a cap) or another cool surface. Then use your fingertips to apply small amounts to the affected area. Massage into your skin until all the foam disappears (UpToDate, n.d.). 

Ketoconazole 2% gel (Xolegel)

Like the foam, this gel is FDA-approved to treat seborrheic dermatitis. Its recommended dose is one application to the affected area once a day for two weeks. 

To apply, use your fingers to spread a thin layer of gel to the targeted area. After applying, keep the spot dry and clean for at least three hours. You can wear makeup or sunscreen over top, just wait at least 20 minutes after putting on the medication. Ketoconazole gel is flammable, so keep it away from heat, flames, and smoke (FDA, 2019). 

Topical ketoconazole can cause localized reactions on the skin where the medication was applied. Common side effects include (UpToDate, n.d.): 

• Burning 

• Tingling

• Redness

• Itching

• Irritation

• Dry skin  

Some people who tried the shampoo also noticed a change in hair texture. Similar to other shampoos, it could cause your hair or scalp to become oily or dry (UpToDate, n.d). 

Unlike topical forms of ketoconazole, oral tablets get absorbed and can trigger side effects all over the body. Adverse effects may include stomach pain, nausea, vomiting, diarrhea, dry mouth, headache, tiredness, sensitivity to light, and loss of appetite. 

Ketoconazole tablets can also cause severe liver damage. For this reason, they aren't commonly used, especially as a first-line treatment. This type is typically reserved for people who can't take other antifungal medications (Sinawe, 2021; Chapman, 2008).  

As far as drug interactions go, it depends on if you're using oral tablets or a topical product. 

Ketoconazole tablets can slow down the metabolism of other medications, leading to dangerously high levels. For your safety, don't take ketoconazole tablets at the same time the following (Burel, 2021): 

• Simvastatin 

• Lovastatin 

• Methadone 

• Alprazolam 

• Midazolam 

• Triazolam 

• Cisapride 

• Dronedarone

If you're prescribed ketoconazole tablets, make sure your provider has a full list of medications you take so they can make adjustments, if needed. 

As for topical products, not as much ketoconazole is absorbed when applied to the skin so there's less risk of interactions (FDA, 2019). Still, talk to a healthcare professional if you have any concerns regarding drug interactions with new medications.  

Seek medical advice from a provider or OB-GYN before using any medication during pregnancy. 

This includes OTC medications and herbal products. Currently, there isn’t a lot of research or data regarding the safety of ketoconazole during pregnancy. Its use during pregnancy depends on the condition being treated, and whether the benefits outweigh the risks. 

The same goes for using ketoconazole topical products while breastfeeding. It's different for oral tablets, which lead to higher ketoconazole levels in the body and breast milk. It's not recommended to breastfeed while taking ketoconazole tablets (FDA, 2019; Burel, 2021).

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Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

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Current version

September 30, 2021

Written by

Hope Chang, PharmD

Fact checked by

Chimene Richa, MD

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About the medical reviewer

Chimene Richa, MD

Dr. Richa is a board-certified Ophthalmologist and medical writer for Ro.