Fungal conditions can cause significant discomfort and cosmetic concerns. Some fungal infections can even progress to a serious condition, particularly if the immune system is not functioning properly.
As many as 9 million outpatient visits occur annually in the United States for fungal concerns. Ketoconazole is an antifungal treatment available in multiple forms, including cream, shampoo, and oral tablets.
This article explores everything you need to know about ketoconazole, from its uses and benefits to its potential side effects and proper usage.
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What is Ketoconazole?
Ketoconazole (Nizoral®) is an antifungal medication approved for treating skin and systemic (throughout the body) infections.
Ketoconazole has FDA-approved uses; however, it is sometimes prescribed off-label for conditions such as Cushing's syndrome and prostate cancer. Off-label prescribing should be discussed with a healthcare provider.
How Ketoconazole Works
Ketoconazole stops fungi from making ergosterol, an essential part of their cell membrane, which prevents them from growing.
Ketoconazole is FDA-approved for treating certain fungal infections. Its ability to inhibit hormone synthesis (e.g., testosterone, cortisol) has led to off-label use in other conditions.
Common Uses of Ketoconazole
Ketoconazole is commonly used for the following skin conditions:
- Tinea versicolor: A fungal skin infection where a normal fungus overgrows. This causes scaly round lesions with more or less pigment than usual.
- Athlete's foot (tinea pedis): A condition where fungi overgrow in damp conditions and cause itching and irritation along the foot and between the toes.
- Ringworm: A contagious skin condition causing a circular, itchy rash on the body.
- Jock itch (tinea cruris): A fungal infection of the groin area that can cause a red, itchy rash and pain.
Ketoconazole is commonly prescribed for these conditions, but alternative antifungal medications may also be considered based on individual patient needs.
Scalp Conditions
Ketoconazole is used to treat seborrheic dermatitis (dandruff) on the scalp. It is formulated in over-the-counter creams and shampoos that can be applied to the scalp in adults and adolescents.
Keep in mind that no shampoos are approved for treating seborrheic dermatitis of the scalp in infants. Talk to your pediatrician about treating this condition in young children.
Systemic Fungal Infections
Ketoconazole is also prescribed for fungal infections that go beyond the skin. These conditions include:
- Blastomycosis: A lung infection caused by a fungus found in moist soil and decaying wood. Immunocompromised individuals or those with underlying conditions may be more susceptible to infection after inhaling fungal spores. In severe cases, the disease can spread to the skin and bones.
- Histoplasmosis: Caused by a fungus that grows in bird and bat droppings, especially in caves and old buildings. Breathing in the spores can cause mild flu-like symptoms, but in some people, especially those with weak immune systems, it can become severe and affect the lungs and other organs.
- Paracoccidioidomycosis: A fungal infection found mainly in South America that affects the lungs first and can spread to the skin, mouth, and other body parts. It is usually caught by breathing in spores from the soil, and it can cause breathing problems, fever, and skin sores.
- Coccidioidomycosis (Valley Fever): A lung infection caused by a fungus found in dry, dusty areas like the southwestern U.S. and Mexico. People can get it by breathing in spores from the air, leading to mild flu-like symptoms, but in some cases, it may cause severe lung or brain infections.
- Chromoblastomycosis: A long-lasting skin infection caused by fungi found in soil, plants, and wood. It usually happens after a fungus enters the skin through a cut, leading to slow-growing, warty skin lesions that can be hard to treat.
How to Use Ketoconazole Safely
It is critical to understand how to safely use ketoconazole.
Dosage Forms and Administration
Tablet (oral) dosing guidelines for ketoconazole are as follows:
- Adults: 200 mg once per day
- Children (2 and up): Typically 3.3-6.6 milligrams per kilogram of body weight (mg/kg)
Topical dosing for ketoconazole is typically:
- Foam 2%: Apply to the affected skin 2 times a day for 1 month.
- Cream 2%: Apply daily to the affected area 1-2 times daily, depending on the type of fungal infection.
- Gel 2% for seborrheic dermatitis: Apply to the skin once a day for 2 weeks.
- Shampoo 1% for dandruff (adult): Use every 3 to 4 days for 2 months, then as needed.
Topical ketoconazole should not be swallowed or applied to the eyes or mucous membranes. The foam should be applied quickly to the area of the skin with a fungal condition. Avoid applying to the hands first.
Always wash your hands after applying topical ketoconazole to avoid transferring the medication. When applying ketoconazole shampoo, apply liberally to the scalp and rinse the product off.
Ketoconazole dosing varies by individual factors, and following a healthcare provider's specific recommendations is essential.
Precautions and Warnings
Ketoconazole in oral form should be taken two hours before any treatments for excess stomach acid due to potential pH changes.
Avoid ketoconazole use in the following scenarios:
- Patients with liver disease (acute or chronic)
- Patients with adrenal insufficiency
- Those with an allergy to ketoconazole or any of its ingredients
- Do not use with HMG-CoA reductase inhibitors, benzodiazepines, antiarrhythmic drugs, and cisapride
- Individuals who are breastfeeding
- Avoid taking this medication with alcohol.
Use caution in the following scenarios:
- Patients with decreased bone density (may increase the risk of fracture)
- A medical provider should weigh the risks and benefits of ketoconazole in a pregnant patient. There is a risk of fetal toxicity based on animal data.
Oral ketoconazole carries an FDA black box warning due to the possible risk of severe liver damage and adrenal suppression. It should only be used when no alternative treatments are available.
Always talk to your medical provider about any medications or supplements you are taking before starting a new treatment.
Tips for Effective Results
Complementary hygiene practices can help prevent fungal infections from returning.
Best practices for preventing athlete's foot (tinea pedis) are:
- Avoid socks made of synthetic fabrics and use natural fibers (e.g., wool).
- Wear shoes with ventilation.
- Use an absorbent powder on your feet to dry up excess moisture (talcum powder).
Hygiene practices for avoiding jock itch (tinea cruris) include:
- Avoid synthetic fibers in underwear, and make sure they are not too tight.
- Use an absorbent powder on the skin for moisture control.
Side Effects and Risks of Ketoconazole
Side effects of ketoconazole may include:
- Gastrointestinal upset (diarrhea, constipation)
- Adrenal insufficiency
- Orthostatic hypotension
- Liver injury
- Jaundice
- Gynecomastia (male breast tissue development)
- Allergic reactions
- Fractures
- Itchy, red, dry skin at the application site
- Dry scalp at shampoo application site
Severe allergic reactions require immediate medical attention. Seek emergency care if you experience difficulty breathing, facial swelling, or severe skin reactions.
Other Considerations
It is crucial to consider ketoconazole's adverse effects and potential complications. Healthcare providers may consider alternative antifungal medications based on a patient's medical history and risk factors.
The choice of ketoconazole as the primary treatment requires a risk-benefit analysis by a healthcare provider.
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Key Takeaways
- Ketoconazole is a medicine that treats fungal infections on the skin and scalp and can also be used for some serious internal infections.
- It works by stopping fungi from making ergosterol, which they need to survive, and can also affect hormone production in the body.
- Common skin conditions treated with ketoconazole include dandruff, athlete's foot, ringworm, and jock itch.
- It is also used for serious fungal infections like blastomycosis, histoplasmosis, and Valley Fever, which affect the lungs and other organs.
- Ketoconazole comes in different forms, including creams, shampoos, gels, and oral tablets, and should be used as directed by a healthcare provider.
- When applied, it can cause side effects like stomach problems, liver issues, allergic reactions, and dry or itchy skin.
- Healthcare providers must consider the benefits and risks of ketoconazole before prescribing it. Alternative antifungal treatments may be recommended depending on individual patient factors.
- Consult your doctor for a personalized recommendation for treating fungal conditions.
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