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Why Am I Shedding After Starting Ketoconazole?

Ketoconazole is a versatile antifungal drug with widespread applications. It is commonly employed to address dandruff issues. It is also utilized off-label as a remedy for hair loss in both men and women, specifically targeting conditions like androgenic alopecia and telogen effluvium that result from an overgrowth of microorganisms on the scalp.

In this guide, we’ll delve into why you might be shedding after using ketoconazole, the difference between normal and abnormal shedding, solutions, and recommendations for those experiencing hair shedding.

What is Ketoconazole?

Ketoconazole is an antifungal medication that is typically used to treat a variety of fungal infections in the body; however, it is also used in the treatment of hair loss conditions like androgenic alopecia (AGA) and telogen effluvium (TE) in the form of topicals and shampoos. Some ketoconazole-based products formulated for hair loss are available over-the-counter (OTC), such as 1% ketoconazole shampoos. In some instances, healthcare professionals may recommend or prescribe stronger ketoconazole treatments.

How Does Ketoconazole Work?

Ketoconazole works as an antifungal agent by disrupting the cell membranes of fungi, inhibiting their growth and replication. The antifungal properties of ketoconazole can help to alleviate these scalp conditions by reducing fungal activity and inflammation. The potential benefit for hair loss conditions such as AGA and TE is that a healthier, less inflamed scalp can create a more favorable environment for hair growth.

Further research suggests that ketoconazole shampoo can reduce dihydrotestosterone (DHT) levels by inhibiting 5 alpha-reductase. Combined usage with finasteride may lead to a more complete treatment.[1]Perez, B.S.H. (2004). Ketoconazole as an adjunct to finasteride in the treatment of androgenetic alopecia in men. Medical Hypotheses. 62(1). 112-115. Available at: … Continue reading

What are the Possible Causes of Hair Shedding After Ketoconazole Use?

Hair shedding after ketoconazole treatment can be disconcerting, but it’s important to understand the potential reasons behind this phenomenon.

Initial Ketoconazole Use

If you have been using ketoconazole for 1-3 months and are experiencing shedding, it may be because the scalp is still adjusting (and responding) to new treatments. Therefore, it’s possible that some of your shedding is due to a positive treatment response.

Ketoconazole Side Effect

According to Nizoral, in rare cases, ketoconazole may cause “inflamed hair follicles, hair loss, or changes in hair texture”.[2]Nizoral, (no date). Nizoral Anti-Dandruff Shampoo Ketoconazole. Nizoral. Available at: https://www.medicines.org.uk/emc/files/pil.6456.pdf (Accessed: 25 October 2023)  You can find out if the hair shedding experienced is due to ketoconazole if you are also experiencing scalp dryness, hair dryness, and itchiness. Furthermore, if scalp redness is also experienced, you may be experiencing an allergic reaction to the product.

Seasonal Shedding

Toward the middle and end of the summer, humans undergo a temporary uptick in shedding due to hair cycle seasonality. While this shedding is primarily unavoidable, it also shouldn’t interfere with the success of any long-term hair loss treatments. So, your current bout of shedding might relate more to seasonality than anything else.

Other Hair Loss Products

Sometimes, the shedding might not be from ketoconazole but rather from other recently added treatments. Treatments like minoxidil shorten the non-growing (telogen) phase, which induces the shedding of club telogen hairs, leading to an increase in hair shedding.[3]Shadi, Z. (2023). Compliance to Topical Minoxidil and Reasons for Discontinuation among Patients with Androgenetic Alopecia. Dermatology and Therapy (Heidelb). 13(5). 1157-1169. Available at: … Continue reading

Ketoconazole Overuse

Overusing ketoconazole can lead to irritation, scalp dryness, and hair loss. Therefore, when using a product such as this, you should use it only as often as recommended by the brand or your doctor.

The Difference between Normal Hair Shedding and Abnormal Hair Loss

Normal hair shedding and abnormal hair loss are distinct processes that can affect the health and appearance of your hair. Understanding their differences is crucial for maintaining good hair care and addressing potential issues.

Normal Shedding

We all shed scalp hair; it’s a normal part of the hair follicle cycle, with the average number of hairs shed daily ranging from 50-100 hairs.[4]American Academy of Dermatology, (no date). Do you have hair loss or hair shedding? American Academy of Dermatology. Available at: … Continue reading These hairs typically fall out with no discomfort or noticeable changes in hair density and do not result in visible thinning or bald spots.

Abnormal Shedding

In contrast, abnormal hair loss, alopecia, involves excessive or sudden hair loss beyond normal shedding. It can be caused by various factors, such as genetics, medical conditions, stress, hormonal changes, medication, or an improper diet.[5]Alessandrini, A., Bruni, F., Piraccini, B.M., Starace, M. (2021). Common causes of hair loss – clinical manifestations, trichoscopy, and therapy. JEADV. 35. 629-640. Available at: … Continue reading Abnormal hair loss often leads to noticeable thinning, receding hairlines, or bald patches. Recognizing and addressing the underlying cause of abnormal hair loss is essential for effective treatment and management.

Solutions and Recommendations for Those Experiencing Hair Shedding Due to Ketoconazole

If the ketoconazole shampoo is causing hair shedding with or without scalp irritation, you do not necessarily have to stop usage. The following solutions may help to reduce symptoms:

  1. Switch from 2% to 1% ketoconazole. This should reduce the “power” of ketoconazole and, thereby, its effect on the hair.
  2. Reduce ketoconazole’s usage frequency and/or scalp contact time. While ketoconazole shampoo is typically used 2-3 times weekly and left on the scalp for up to 15 minutes, these usage parameters can irritate many people’s scalps. The simplest way to troubleshoot this is to reduce your use. Opt for 1-2 times weekly ketoconazole shampooing and/or only leave in the shampoo for 2-5 minutes.
  3. Add in a conditioner. After shampooing with ketoconazole, add in a conditioner. This should help moisturize the scalp and hair, reducing any hair texture changes caused by scalp/hair dryness.

If you decide to make any of the above changes, it’s important to give it time to see if the shedding stops or reduces. Assessing the effects of any change in hair care products or routines typically takes several weeks.

If this does not resolve the hair shedding, consider stopping the shampoo and/or seeking help from our community.

References

References
1 Perez, B.S.H. (2004). Ketoconazole as an adjunct to finasteride in the treatment of androgenetic alopecia in men. Medical Hypotheses. 62(1). 112-115. Available at: https://doi.org/10.1016/s0306-9877(03)00264-0
2 Nizoral, (no date). Nizoral Anti-Dandruff Shampoo Ketoconazole. Nizoral. Available at: https://www.medicines.org.uk/emc/files/pil.6456.pdf (Accessed: 25 October 2023)
3 Shadi, Z. (2023). Compliance to Topical Minoxidil and Reasons for Discontinuation among Patients with Androgenetic Alopecia. Dermatology and Therapy (Heidelb). 13(5). 1157-1169. Available at: https://doi.org/10.1007/s13555-023-00919-x
4 American Academy of Dermatology, (no date). Do you have hair loss or hair shedding? American Academy of Dermatology. Available at: https://www.aad.org/public/diseases/hair-loss/insider/shedding#:~:text=It ‘s%20normal%20to%20shed%20between,this%20condition%20is%20telogen%20effluvium. (Accessed: 25 October 2023)
5 Alessandrini, A., Bruni, F., Piraccini, B.M., Starace, M. (2021). Common causes of hair loss – clinical manifestations, trichoscopy, and therapy. JEADV. 35. 629-640. Available at: https://doi.org/10.1111/jdv.17079

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