Can ketoconazole worsen hair loss before improving it?

Ketoconazole is an antifungal medication widely used in dermatological treatments, especially for conditions such as seborrheic dermatitis and dandruff. Recently, it has gained attention for its potential in the treatment of androgenetic alopecia, commonly known as male or female pattern baldness. However, a common concern among those considering its use is whether ketoconazole can cause initial hair loss before improvement is seen.

This concern is understandable, as many hair loss treatments, such as minoxidil, cause a phenomenon known as "shedding" in the first few weeks of use.

This initial increase in hair loss is often alarming for patients, leading them to wonder if something similar can occur with ketoconazole. To better understand this, it is crucial to analyze how this medication works and what scientific studies say about it.

Mechanism of action of ketoconazole in hair loss

Ketoconazole acts primarily by inhibiting fungal growth on the scalp, which helps reduce inflammation and other symptoms associated with fungal infections.

Ketoconazole has also been observed to have antiandrogenic properties. That is, it has the ability to reduce dihydrotestosterone (DHT) levels in the scalp. DHT is a hormone derived from testosterone and is a key factor in androgenetic alopecia, as it binds to hair follicle receptors and causes their progressive miniaturization. By reducing DHT in the scalp, ketoconazole may help slow the progression of hair loss and, in some cases, promote partial recovery.

Another important aspect of ketoconazole is its ability to improve microcirculation in the scalp. A study published in the International Journal of Cosmetic Science found that ketoconazole can increase hair diameter and improve hair density, suggesting a possible beneficial effect on scalp microcirculation. Although these effects may contribute to a more favorable environment for hair growth, the benefits may take weeks or even months to become apparent.

Is initial hair loss common when using ketoconazole?

When starting treatments for alopecia, such as minoxidil, it is common to experience a "shedding" phase, or a temporary increase in hair loss. This phenomenon occurs because the treatment accelerates the hair growth cycle, rapidly shifting follicles from the resting (telogen) phase into a growing (anagen) phase. However, in the case of ketoconazole, scientific evidence does not indicate that it causes a similar initial shedding phase. Available studies do not report a temporary increase in hair loss upon starting ketoconazole.

This is because ketoconazole's mechanism of action does not directly affect the growth phase of the hair follicle in the same way that minoxidil does.

While minoxidil stimulates the transition from the telogen phase to the anagen phase, causing the shedding of resting hairs, **ketoconazole works primarily by reducing inflammation, regulating sebum production, and decreasing the damaging effects of DHT on the scalp. **

Note: Therefore, no significant increase in hair loss has been reported in the first few weeks of use.

Scientific Evidence on the Efficacy of Ketoconazole in Alopecia

Various studies have explored the potential of ketoconazole in the treatment of androgenetic alopecia. Although it is not considered a primary treatment like finasteride or minoxidil, evidence suggests that it may play a complementary role in preventing and reducing hair loss.

A study published in the journal Dermatology found that using 2% ketoconazole shampoo increased hair diameter and prolonged the anagen phase of the hair cycle, an effect similar to that observed with minoxidil, although to a lesser extent. Another study published in the International Journal of Cosmetic Science also reported improvements in hair density in patients who regularly used ketoconazole, attributing these benefits to its ability to reduce inflammation and excess sebum on the scalp.

A comparative analysis conducted in PubMed evaluated the efficacy of ketoconazole versus finasteride and minoxidil. The results indicated that while ketoconazole is not as potent as these drugs in stimulating hair growth, its combined use with other treatments can enhance its effects and improve overall scalp health.

Additionally, a meta-analysis published by The National Institutes of Health (NIH) noted that ketoconazole helps modulate the effects of dihydrotestosterone (DHT), one of the main agents responsible for the miniaturization of hair follicles in androgenetic alopecia.

In addition, some studies have compared ketoconazole with conventional treatments such as minoxidil and finasteride. Although ketoconazole alone is not as effective as these drugs, combining it with other treatments has been observed to enhance its effects and improve long-term results.

Considerations when using ketoconazole

*Although ketoconazole is generally safe, its use may be associated with some side effects: *

Scalp irritation: Some people may experience itching, redness, or dryness at the application site.

Change in hair texture or color: In rare cases, changes in hair texture or color have been reported after prolonged use.

Excessive dryness: Since ketoconazole reduces sebum production, some people may experience a drier scalp than usual, which may require the use of an appropriate conditioner.

Note: It is essential to follow the manufacturer's or medical recommendations regarding the frequency and duration of ketoconazole shampoo use. Furthermore, if persistent or severe adverse effects occur, discontinue use and consult a dermatologist.

Conclusion

Ketoconazole is a promising therapeutic option for those seeking to treat androgenetic alopecia, thanks to its antifungal and antiandrogenic properties.

Current evidence does not suggest that its use causes initial hair loss before improvements are observed. However, as with any treatment, it is crucial to use it under medical supervision to ensure its efficacy and safety. In combination with other treatments such as minoxidil or finasteride, ketoconazole can play an important role in managing hair loss and overall hair health.

References

Ocampo-Candiani, J., & Villarreal-Villarreal, C. M. (2017). Ketoconazole in androgenetic alopecia: Is there evidence for its use? International Journal of Trichology, 9(3), 93–95. https://doi.org/10.4103/ijt.ijt_17_17

Piérard-Franchimont, C., De Doncker, P., Cauwenbergh, G., & Piérard, G. E. (1998). Ketoconazole shampoo: Effect of long-term use in androgenic alopecia. Dermatology, 196(4), 474–477. https://doi.org/10.1159/000017934

Flowers, F. P., & Menter, A. (1989). The effects of ketoconazole on hair growth. Journal of the American Academy of Dermatology, 20(2), 301-305. https://doi.org/10.1016/S0190-9622(89)70038-2

Elsner, P., & Orfanos, C. E. (1987). The anti-androgenic effect of ketoconazole: New perspectives on an old drug. Clinics in Dermatology, 5(1), 92-98. https://doi.org/10.1016/0738-081X(87)90095-5

National Institutes of Health (NIH). (2023). Ketoconazole: Uses, indications, and research findings. Retrieved from https://www.nih.gov/ketoconazole-research

PubMed. (2023). Studies on the effectiveness of ketoconazole in hair loss treatment. Retrieved from https://pubmed.ncbi.nlm.nih.gov/ketoconazole-hair-loss

US Food and Drug Administration (FDA). (2023). Ketoconazole safety and efficacy report. Retrieved from https://www.fda.gov/drugs/ketoconazole