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Dealing with hair loss is a lot of things: stressful, defeating, confusing, and complex. If you’re noticing breakage, more hair in the drain, or thinning, chances are you’ve considered trying anything to help restore your hair to its fullest potential. And if you’re losing hair while also going through the ups, downs, and unexpectedness of midlife, you’re probably even more concerned about what’s going on.
For some people experiencing hair loss—including many menopausal women—trying to reverse it means adding a surprising product to their routine: dandruff shampoo. This “hack,” so to speak, has gone viral a few times in recent years, driven by social media-based conversation about the supposedly surprising effects of ketoconazole, the key ingredient in popular dandruff shampoo Nizoral. Board-certified dermatologists have mentioned it in their own social videos too: Heather Kornmehl, Neera Nathan, and Joyce Kim let their followers know it might be worth pursuing for hair loss. (Dr. Kim rated it a 7.5/10 as a hair loss treatment option.) Shereene Idriss praised its benefits for the scalp and claimed it “helps fight that pesky testosterone that causes you to lose your hair.”
With all this compelling information coming at you from your phone screen, why wouldn’t you want to pop over to your local big-box retailer, buy a $17 bottle of Nizoral, and watch your hair magically grow back? We hate to burst your bubble, but dandruff shampoo likely won’t solve your hair loss issues on its own. However, there is some truth to the social media chatter. To learn why some people are seeing noticeable results and whether or not ketoconazole can replace Rogaine and other treatments, we tapped a handful of derms to share their unfiltered thoughts about the role Nizoral plays in a hair-loss routine, if at all.
What are ketoconazole and Nizoral? Why is everyone talking about them for hair loss?
If you’ve purchased anti-dandruff shampoo in the past, the word ketoconazole might sound familiar. It’s an ingredient used in dandruff shampoos, with Nizoral being the main over-the-counter shampoo to feature it. “Ketoconazole is an antifungal we use for dandruff and seborrheic dermatitis,” says Kautilya Shaurya, MD, a board-certified dermatologist in New York City. It’s commonly recommended by dermatologists as a way to banish dandruff, but does the blue bottle have more benefits beyond the flakes? (Hair-care benefits, we mean: It can also help with rosacea and ringworm, apparently, but that’s another story.)
According to Dr. Shaurya, there is “modest evidence” that ketoconazole can help with hair loss—emphasis on modest. He mentions an oft-cited study from 1998 that showed promising results, with men using 2% ketoconazole shampoo several times a week. The participants “saw gains in hair density and thickness roughly comparable to 2% minoxidil.” However, he flags that it was a small study that doesn’t have a ton of follow-up research, and that the Food and Drug Administration has not approved ketoconazole for hair loss treatment; dermatologists don’t typically prescribe it as a standalone for hair loss, but rather for patients with dandruff or seborrheic dermatitis. (In the United States, you can purchase 1% ketoconazole over the counter, but anything higher than that requires a prescription. If someone is claiming they’ll sell you 2% Nizoral on TikTok Shop, don’t hit that purchase button.) And Caren Campbell, MD, a board-certified dermatologist in San Francisco, flags that there isn’t strong research that supports its efficacy in women.
If you’re wondering why most of the studies are 30+ years old, Dr. Campbell says it’s likely because “we have better medications to use with a bigger impact [on hair loss].” (More on that below.) Dr. Shaurya adds that ketoconazole is sold as a generic, over-the-counter drug and is well-established (with data collection) as an antifungal. “That distinction is important in understanding why there is not more contemporary research,” he says. “The research is extensive, just not on hair loss. It has never gone through the large trials the FDA would require to approve it for hair loss.” In other words, we know this product is safe, we just don’t have a bunch of clinical testing that shows it actually prevents or reverses hair loss.
Are there theories about how ketoconazole may help with hair loss?
Hair loss can happen for a variety of reasons. For some people, it’s genetic. For others, it’s due to stress, specific medical conditions, or hormonal shifts, like the ones you go through postpartum or, yep, you guessed it, menopause. “Hair loss during menopause is influenced by hormonal changes, particularly declining estrogen levels,” explains Dawn Queen, MD, a board-certified dermatologist in New York City. Because estrogen plays “an important role” in the hair growth cycle, women may notice shedding and reduced hair density as their estrogen levels decline. She adds that declining estrogen levels can also lead to increased androgen activity. Androgens are sex hormones (like testosterone) that impact the hair growth cycle, and increased activity can cause thinning or follicle shrinkage in genetically predisposed women.
Many videos about ketoconazole shampoo for menopausal women in particular claim that it blocks dihydrotestosterone, or DHT, which is an androgen that plays a key role in hair follicle shrinkage in people who are genetically predisposed to hair loss, especially men. Dr. Queen says that while ketoconazole has demonstrated anti-androgen effects that could potentially benefit androgenetic alopecia—another name for male- and female-pattern hair loss—in a lab study, meaningful results have yet to be seen in humans. “Clinically, there is limited evidence that ketoconazole shampoo meaningfully reduces DHT levels in the scalp,” she notes.
Kseniya Kobets, MD, a board-certified dermatologist, adds that while the DHT-blocker theory “has biologic plausibility” due to ketoconazole’s potential anti-androgen effects, it’s important to remember that female-pattern hair loss isn’t “simply male-pattern hair loss in women.” She also notes that “most women with pattern thinning don’t have elevated androgens, and genetics and other factors also contribute” to their hair loss. “DHT doesn’t explain everything,” Dr. Kobets continues. “Lower scalp levels of aromatase, which converts androgens into estrogens, may also play a role and science is still untangling these pathways.”
Even if the result of that untangling did point to DHT being responsible for most female-pattern hair loss and to ketoconazole as an effective DHT blocker, that doesn’t necessarily mean a shampoo would be the best way to administer it. “We don’t know how much DHT blockade a rinse-off shampoo delivers,” Dr. Kobets says. Because shampoo isn’t absorbed into the body in the same way as, say, an oral medication, doctors can’t assume it’s making the same impact.
But some people who are consistently using ketoconazole-containing shampoos like Nizoral are seeing regrowth. Dr. Shaurya says three things are “likely” happening here: “Pattern hair loss often involves low-grade inflammation around the follicle, and ketoconazole knocks down Malassezia, the yeast behind dandruff, while calming the scalp directly,” he explains. This helps promote regrowth. And because ketoconazole treats seborrheic dermatitis, which can drive shedding, it may help reduce hair fallout. Dr. Queen agrees that ketoconazole’s true power is establishing a healthy scalp environment from which new hair follicles can grow.
However, less visible shedding or having healthier-looking hair is not the same as new growth, Jenna Queller, MD, a board-certified dermatologist in Palm Beach, points out. That’s why you see language like “leads to fuller looking hair” rather than “reverses hair loss” on hair-care products; the latter is a medical claim only FDA-approved drugs can make. Ketoconazole shampoos’ viral popularity “should not be confused with strong clinical evidence for hair regrowth,” Dr. Queller says.
Dr. Campbell, Dr. Kobets, and Dr. Shaurya all think it shows enough potential to be a worthwhile trick to try. “I wouldn’t consider [ketoconazole shampoo] a primary hair-loss treatment, as the evidence is still fairly limited,” Dr. Campbell says. “But there is enough data to make it a reasonable add-on.” Dr. Shaurya concurs. “It’s inexpensive, low-risk, and easy to work into a routine, so I suggest it often, especially when someone also has flaking, itching, or an oily scalp,” he explains. “But it’s never my only treatment for someone actively thinning, and diagnosis comes first.” For example, someone experiencing hair loss could be dealing with iron deficiency, thyroid problems, stress shedding, or alopecia areata (an autoimmune disease), and a shampoo simply can’t fix that.
While derms are fine with patients using the shampoo as part of a routine, it doesn’t replace existing treatments with more clinically proven results. For example, Dr. Queen’s go-tos for hair loss are topical minoxidil, low-dose oral minoxidil, and, in select patients, spironolactone or finasteride. Other options, she adds, include platelet-rich plasma (PRP) injections and low-level laser therapy.
Risks of using ketoconazole for hair loss
Dr. Queen cautions her patients not to overuse ketoconazole shampoo, as it can leave the hair shaft dry and brittle; this is particularly of note for menopausal women using the shampoo, as dry hair is another fun side effect of the hormonal shift. (People with damaged hair, chemically treated hair, and textured hair may also experience this side effect.) Since ketoconazole shampoo can be drying, Dr. Queen advises, it’s not a bad idea to follow up with a moisturizing shampoo and conditioner or try a conditioning mask post-shampoo.
Dr. Queller agrees, saying, “Ketoconazole shampoos can cause dryness, irritation, or changes in hair texture in some people, potentially making hair more prone to tangling and breakage, particularly if it is already fragile or chemically treated.” This could be why some people have claimed that the shampoo caused them to lose hair, but Dr. Queller notes that “reports alone don’t establish that ketoconazole directly causes hair loss.” In general, results are not one-size-fits-all; a quick scroll through the #femalehairloss subreddit reveals a fairly even split between those who found success and those who did not.
A final word
When in doubt, talk to your derm. “The problem with TikTok is that it removes the ‘diagnosis’ step,” says Dr. Campbell. “A product that helps someone with inflammatory scalp hair loss won't help someone with androgenetic alopecia, and vice versa.” If you find joy in doing your own research, Dr. Kobets recommends looking at sources outside of any apps with an algorithmically-driven infinite scroll , like reading published studies on PubMed, and asking “Studied in whom, for which type of hair loss, and in what formulation?” when you’re in research mode. “An ingredient working in a laboratory doesn’t prove your shampoo grows hair,” she says. “Look for comparison groups, measured results, and other treatments participants were using.” Before-and-after photos can help, but lighting and styling can also make a difference, she adds.
And again, before you suds up, check with a board-certified dermatologist to make sure you’re treating what’s really going on, because hair loss can happen for so many different reasons, and one person’s experience may not be the same as yours. “If a trend sounds too good to be true, it usually is,” says Dr. Campbell. “Off-label doesn’t automatically mean ineffective (we often use treatments off-label in dermatology) but evidence still matters,” adds Dr. Kobets. “Be cautious when ‘may help’ becomes ‘clinically proven,’ or one product promises to fix every type of hair loss. Social media can start the conversation; your diagnosis should guide the treatment.”
Meet the experts
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- Caren Campbell, MD, is a board-certified dermatologist in San Francisco
- Kseniya Kobets, MD, is a board-certified dermatologist and director of cosmetic dermatology at Montefiore Einstein Advanced Care in New York
- Dawn Queen, MD, is a board-certified dermatologist in New York City
- Jenna Queller, MD, is a board-certified dermatologist in Palm Beach
- Kautilya Shaurya, MD, is a board-certified dermatologist in New York City