Medication

Ketoconazole

An antifungal cream and shampoo used for dandruff, seborrheic dermatitis, tinea versicolor and ringworm. The tablet form is no longer used for skin infections because of liver risk.
Dr. Schwarz, MD · Board-certified dermatologistLast reviewed September 8, 2026
16:9 hero for Ketoconazole. Never cropped: the tone strip and the corner logo depend on the full frame.

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This page is the cream and the shampoo, not the tablet. Regulators pulled the tablet's skin and nail uses after cases of serious liver injury, so if someone offers you oral ketoconazole for a fungal skin infection, question it. Ketoconazole shampoo is my standard answer for dandruff and seborrheic dermatitis, and nearly everyone makes the same mistake: it has to sit on the scalp three to five minutes before rinsing, or it does very little. Seborrheic dermatitis is long term, so once things are calm most people do best using it weekly rather than stopping and waiting for the flakes to come back.

— Dr. Schwarz, Board Certified Dermatologist

Key Facts

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Also calledNizoral, Nizoral A-D, Xolegel, Extina
Drug classImidazole antifungal
Applied as2% cream, 2% shampoo, 1% shampoo, 2% gel, 2% foam
Typical course2 to 4 weeks to control, then ongoing maintenance for dandruff and seborrheic dermatitis
Time to workAbout 1 to 2 weeks
Prescription onlyThe 1% shampoo is sold over the counter; the 2% strengths are prescription in most places

What It Is

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Ketoconazole is an antifungal for the skin and scalp. It has been in use since the 1980s and is among the most widely used topical antifungals in dermatology. It treats dandruff and seborrheic dermatitis, tinea versicolor, ringworm, jock itch, athlete's foot, yeast in skin folds, and yeast folliculitis on the chest and back. The tablet is a different matter. In 2013, regulators in the United States and Europe removed its use for fungal infections of the skin and nails after reports of severe liver injury, adrenal effects and dangerous drug interactions. Oral ketoconazole is now kept for a few serious internal infections and one hormonal condition. Everything below is about the topical forms.

How It Works

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Ketoconazole blocks a fungal enzyme needed to make ergosterol, the molecule fungi use to build their cell walls. Without it the wall leaks and the fungus cannot grow. Almost none is absorbed through skin, which is why the topical form does not carry the liver and hormone risks of the tablet.

For dandruff and seborrheic dermatitis the target is Malassezia, a yeast that lives on everyone's skin. Some people react to it with redness, greasy scale and itching. Ketoconazole reduces the yeast and the flaking settles.

It also calms inflammation directly, separately from its effect on the yeast. That is why it suits seborrheic dermatitis, as much inflammation as infection, and why it can be used long term where a steroid cannot.

Here is where Ketoconazole acts in the skin, and what the others do instead.

About Ketoconazole
Compare
Skin basics
BARRIEREPIDERMISDERMISPOREOILGLANDKILLS YEASTSTAYS ON THE SURFACESTOPS PLUGS FORMINGUNCLOGS THE POREKILLS BACTERIALOWERS OIL PRODUCTIONKILLS MITES

The yeast involved here lives on everyone's skin and only causes trouble when it overgrows in oil. Ketoconazole reduces it, which is why the flaking and itching settle and why it comes back if treatment stops for good. The workhorse, as a shampoo or a cream.

Ketoconazole works in the outer layer where the yeast lives, and stays there. It does not need to go deeper.

Retinoids change how the lining of the pore sheds its cells, so the plug that starts a spot stops forming in the first place. That is why they prevent spots rather than treat the ones already there, and why the first weeks can look worse before they look better.

Salicylic acid dissolves in oil, so it gets down inside the pore rather than sitting on the surface, and loosens the plug of dead skin and sebum blocking the way out.

This works on the bacteria growing in an inflamed pore. Less bacteria means less for the immune system to react to, which is what takes the redness and soreness out of a spot.

This works upstream of the spot, on the gland itself. Less oil means fewer plugs, less for bacteria to feed on and less inflammation, which is why it changes the pattern rather than clearing one spot.

Everyone carries these mites in their follicles. In some people the immune system reacts to them, and reducing their number reduces the bumps and the redness that come with them.

The outer film of dead cells and oil. It holds water in and keeps irritants out, and it is thinner than a sheet of paper. Almost every dry, itchy, stinging skin problem starts here.

The outer layer, and the only one anything in a jar reaches. It renews itself constantly: a cell made at the bottom takes about a month to reach the surface and flake off. Most of what a skincare product does, it does here.

The living layer underneath, holding the blood vessels, the nerves and the collagen. It is where lasting change happens and it is hard to reach: most of what is sold for the skin never gets this far.

What It Treats

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Seborrheic Dermatitis
Seborrheic Dermatitis
Strong evidence
The first thing to reach for, as a 1% shampoo used two or three times a week. It reduces the yeast, so the immune system has less to react to, and most people are clear in one to two weeks. It only works if it goes onto the skin and stays there five minutes — rinsing it straight out is the single most common reason people think it failed.
Jock Itch
Strong evidence
The prescription-strength azole cream, used once or twice a day for two to four weeks. It is the usual next step when a pharmacy cream has not cleared it, or when the rash is wide. It carries the same rule as the others: treat past the visible edge, and keep going after the skin looks normal.
Dandruff
Dandruff
Strong evidence
The 1 percent shampoo on the shelf is a proper antifungal and one of the most effective things you can buy for dandruff. Twice a week during a flare, then once a week to hold it. Pairing it with zinc pyrithione and alternating the two tends to keep working better over months than either one used alone.
Scalp Psoriasis
Scalp Psoriasis
Moderate evidence
An antifungal shampoo that does nothing to psoriasis itself but clears the seborrheic flaking sitting on top of it, which many people with scalp psoriasis also have. It is worth adding when the flakes are greasy and yellow as well as dry and silvery. If your scale is purely psoriasis, it will not help.

Not the Best For

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Nail fungus
Doesn't work
Nothing applied to the skin penetrates the nail plate in useful amounts, so nail infection is treated from the inside.
The uneven color after tinea versicolor
Doesn't work
The fungus clears in a couple of weeks, but the lighter or darker patches left behind take weeks to months. They can stay obvious through the summer because that skin does not tan the same way. This is not treatment failure.
Athlete's foot across the whole sole
Doesn't work
The moccasin pattern that covers the sole is thick and widespread, and a cream rarely clears it on its own.

Forms

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The 1% shampoo is over the counter, milder, and suits ongoing maintenance.

The 2% shampoo is prescription strength, the usual starting point for scalp seborrheic dermatitis, and for tinea versicolor used as a body wash.

The 2% cream is for skin rather than scalp, so ringworm, jock itch, athlete's foot, yeast in folds, and seborrheic dermatitis on the face and chest.

The 2% gel and 2% foam are for hairy areas and people who dislike cream. They dry quickly, cost considerably more, and both contain alcohol that stings broken skin.

Strengths

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Two strengths. The practical difference is how easy each is to get.

WeakestStrongest
1% shampoo2% cream, shampoo, gel or foam
The over-the-counter strength
1% shampoo
Over the counter for dandruff, and a reasonable maintenance option.
The prescription strength
2% cream, shampoo, gel or foam
The treatment strength for seborrheic dermatitis, tinea versicolor and ringworm.

Basics

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When to Apply
For the shampoo, twice a week on wet hair. Lather it in, leave it on the scalp three to five minutes, then rinse. Contact time is what works, not volume. For the cream, a thin layer once or twice a day over the area and a little past its edge.
How to Start
Twice-weekly shampoo, or daily cream, for the first two to four weeks. Tinea versicolor is often treated with the shampoo as a body wash, left on five minutes, daily for a few days or weekly for a few weeks. Athlete's foot needs longer, often about six weeks.
If It Irritates
Mild stinging, dryness or an itchy scalp early on usually settles. Rinsing more thoroughly, dropping to once a week, or switching from gel or foam to cream generally fixes it. A rash that worsens each time you use it may be an allergy, and needs a look.
If It's Not Working
Give it two full weeks used correctly, with the contact time. If the scalp is no better, the reasons are usually rinsing too soon, a different diagnosis such as psoriasis, or a fungus that needs a tablet. Rotating with selenium sulfide, zinc pyrithione or ciclopirox often helps.

Sample Routine

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Here is where Ketoconazole sits in a day, and what goes around it. Pick what you are treating and what your skin is like, and the rest of the routine changes to suit.

What to Expect

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First wash | Using it
Lather, leave it on a few minutes, then rinse. Twice a week on the scalp.
Days 1 to 7 | Itch settles
Itching and greasiness ease first, often within the first few washes.
Weeks 1 to 2 | Flaking drops
Scale on the scalp or sides of the nose drops substantially, so judge it here. Tinea versicolor clears in the same window.
Weeks 2 to 4 | Skin infections clear
Ringworm, jock itch and yeast in folds clear here. Treat a little beyond the visible edge, since the fungus extends past it, and keep the fold dry.
Around 6 weeks | Athlete's foot
The soles are thick and slow, so this takes longer.
Beyond 4 weeks | Maintenance
For dandruff and seborrheic dermatitis, move to once a week or every other week rather than stopping. This is control, not a cure.

What to Avoid

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  • Rinsing the shampoo out straight away Contact time is the treatment. Three to five minutes on the scalp is the difference between working and not.
  • Using it in or near the eyes It stings sharply. Rinse with water if it gets in.
  • The gel or foam on broken or raw skin Both contain alcohol and sting badly there.
  • Stopping the moment the flakes go Seborrheic dermatitis returns within weeks for most people. A weekly wash keeps it quiet.
  • Scrubbing or picking scale off the scalp It irritates the skin, and irritated skin flakes more.
  • Expecting a nail to respond Topical antifungals do not reach through the nail plate.

Monitoring

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No blood tests and no routine monitoring for the cream, shampoo, gel or foam. Absorption through intact skin is minimal, and the serious risks belong to the tablet.

People use this for years. Seborrheic dermatitis and dandruff are long-term conditions, and continuing at a lower frequency is the normal plan, not a sign something has gone wrong.

The exception to watch for is an allergic contact reaction, a rash that worsens each time it is used. Uncommon, but it happens, and it is a reason to stop and have it looked at rather than to use it more often.

Oral ketoconazole is the version that needs liver blood tests, heart tracings and interaction checks. It is not used for skin infections.

If You Stop

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Stop the cream once the infection has cleared, usually about a week after the skin looks normal, so nothing is left at the edges. The shampoo is different. Dandruff and seborrheic dermatitis are driven by a yeast that lives on the skin permanently, so stopping usually means the flaking returns over the following weeks. No rebound and no withdrawal, it just goes back to how it was. Step down rather than stop, twice weekly while it is active, then once a week or every other week to hold it. Some people need it only in winter or during stressful periods.

Cost

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The 1% shampoo is over the counter and inexpensive, and store-brand versions work the same for less. The 2% shampoo and cream are generic and among the cheaper prescriptions in dermatology. The 2% gel and foam cost much more, and insurance often requires trying the cream or shampoo first. They are worth the difference mainly for hairy areas where cream is impractical. Selenium sulfide and zinc pyrithione shampoos are cheaper alternatives with reasonable evidence, and rotating between them keeps costs down.

Ask Your Doctor

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If a rash gets worse each time you apply it: That pattern suggests allergy to the product rather than irritation.
If the scalp has thick, silvery, well-defined plaques: That looks more like psoriasis, which needs different treatment.
If the flaking is on an infant's scalp
Cradle cap is managed differently, and often needs no treatment early on.
If you are offered ketoconazole tablets
For a skin or nail infection, ask why, since that use was withdrawn and safer tablets exist.
If a fungal rash keeps returning
Recurring or widespread infection despite correct use can point to diabetes, a suppressed immune system, or a pet or family member as the source.
If you are pregnant or breastfeeding
Ask the doctor managing your pregnancy before using it, and keep it off the chest area if breastfeeding.

How It Compares

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Selenium sulfide shampoo
The same
similar evidence for dandruff and tinea versicolor, and cheaper. Has a stronger smell and can discolor light or treated hair.
Zinc pyrithione shampoo
Worse
widely available and gentle, with good evidence for mild dandruff. Generally less effective than ketoconazole for stubborn seborrheic dermatitis.
Ciclopirox shampoo or cream
The same
comparable results, and a useful alternative to rotate to when ketoconazole seems to stop helping.
Terbinafine cream
Different job
more effective than ketoconazole for ringworm, jock itch and athlete's foot, and often a shorter course. Does not treat seborrheic dermatitis or tinea versicolor, because it does not cover the yeast behind them.
Clotrimazole or miconazole cream
Better
same family, similar results, cheaper and easier to buy. Reasonable for straightforward ringworm or yeast in a fold.
A mild topical steroid
Different job
settles the redness and itch of seborrheic dermatitis faster, but does nothing about the yeast and cannot be used long term on the face. Often used briefly alongside ketoconazole rather than instead of it.
Tacrolimus or pimecrolimus cream
Different job
steroid-free options for facial seborrheic dermatitis that needs long-term treatment. More expensive, and they can sting at first.

Myths

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  • "Ketoconazole shampoo causes hair loss." It does not. It has been studied for a possible small benefit in pattern hair loss, though the evidence is thin. Shedding after starting is usually a flaky, inflamed scalp that was already shedding, or more frequent washing.
  • "Dandruff means dirty hair." It is a reaction to a yeast that lives on everyone's skin, plus skin oil and individual sensitivity. Washing more does not prevent it, and over-washing makes an irritated scalp worse.
  • "The tablet is stronger, so ask for that instead." Oral ketoconazole had its skin and nail uses removed because of serious liver injury, adrenal effects and drug interactions. It is not the stronger option, it is the one withdrawn from that role.
  • "Once the flakes stop, you are cured." Seborrheic dermatitis is long term. Treatment controls it, and most people need ongoing maintenance.
  • "The pale patches left after tinea versicolor mean it is still there." Uneven color is the aftermath. The fungus is usually gone before the color evens out, and that can take months.

Questions Patients Ask

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How long do I leave the shampoo on?

Three to five minutes before rinsing. Rinsing straight away is the most common reason people think it failed.

How often should I use it?

Twice a week while it is active, then once a week or every other week to keep it quiet.

Will it make my hair fall out?

No. It has been looked at for a small possible benefit in pattern hair loss, not as a cause.

Can I use it on my face?

The cream, yes, for seborrheic dermatitis on the sides of the nose, eyebrows and hairline. Keep it away from the eyes.

Why are the pale patches still there after treatment?

Tinea versicolor leaves uneven color behind after the fungus is gone. It fades over weeks to months, and looks more obvious once the surrounding skin tans.

Should I be taking the tablet instead?

No. Oral ketoconazole had its skin and nail uses withdrawn because of serious liver injury and drug interactions. If a tablet is needed, terbinafine, fluconazole or itraconazole is used.

References

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