Ketoconazole Shampoo for Fungal Infections of the Scalp
For fungal infections of the scalp, ketoconazole 2% shampoo should be used twice weekly for 2-4 weeks as initial treatment, followed by once-weekly application for prophylaxis to prevent recurrence. 1
Indications and Mechanism
Ketoconazole shampoo is effective against:
- Tinea capitis (scalp ringworm)
- Seborrheic dermatitis
- Dandruff
- Pityrosporum (Malassezia) infections
Ketoconazole works by inhibiting fungal cell wall synthesis and has potent activity against Malassezia species (formerly known as Pityrosporum ovale), which are implicated in the pathogenesis of seborrheic dermatitis and dandruff 1, 2.
Recommended Dosage and Application
Initial Treatment Phase:
- Apply ketoconazole 2% shampoo to wet hair and scalp
- Massage thoroughly for 1-2 minutes
- Leave on scalp for 3-5 minutes
- Rinse thoroughly
- Use twice weekly for 2-4 weeks 1, 3
Maintenance/Prophylactic Phase:
- After successful initial treatment, use once weekly to prevent recurrence 1
- Prophylactic use significantly reduces relapse rates compared to placebo (19% vs 47% relapse) 1
Efficacy
Ketoconazole 2% shampoo demonstrates excellent efficacy:
- 88% of patients show excellent response after 2-4 weeks of twice-weekly use 1
- 89% of patients become free of lesions or show improvement compared to only 44% with placebo 4
- 73% improvement in total dandruff severity score after 4 weeks 3
- Significantly better than zinc pyrithione 1% shampoo in severe dandruff and seborrheic dermatitis 3
- Better tolerated than selenium sulfide 2.5% shampoo with similar efficacy 5
Important Considerations
Topical therapy alone is not recommended for tinea capitis: While ketoconazole shampoo can help reduce transmission of spores, oral antifungal therapy (such as griseofulvin, terbinafine, or fluconazole) is generally required for complete eradication of tinea capitis 6
Adjunctive therapy: For tinea capitis, ketoconazole shampoo should be used as an adjunct to oral antifungal therapy to reduce spore transmission 6
Denture-related candidiasis: If treating oral thrush associated with dentures, disinfection of the denture in addition to antifungal therapy is recommended 6
Treatment duration: While most cases respond to 2-4 weeks of treatment, some may require longer therapy. Clinical improvement should be evident within the first 1-2 weeks of treatment.
Side effects: Ketoconazole shampoo is generally well-tolerated with minimal side effects, which is an advantage over alternatives like selenium sulfide 5
Special Populations
For immunocompromised patients or those with recurrent infections, more aggressive treatment regimens may be necessary, potentially including oral antifungal agents in addition to topical therapy 6, 7.
Follow-up and Monitoring
- Evaluate clinical response after 2-4 weeks of treatment
- If no improvement is seen, consider alternative diagnoses or treatments
- For persistent or recurrent infections, consider maintenance therapy with once-weekly applications 1