Nizoral: Let’s Get Your DandrOFF

There is no need to feel embarrassed about your dandruff! Dandruff affects up to 40% of men and women over age 30, which means it is more common than you think¹. We have a lot good information to answer all of your questions about dandruff and Nizoral outlined here:

• What Causes Dandruff?
• What Is Nizoral?
• How Does Nizoral Work?
• What Does the Evidence Say?
• Is Nizoral Safe To Use?
• What Are Some Possible Side Effects With Nizoral Shampoo?
• What Are Other Ways To Get Rid Of Dandruff?
• Bottom Line

What Causes Dandruff?

Our skin layer continually replaces itself and as a result, dead skin cells are shed (this is normal). In people with dandruff, this cycle of cell turnover is usually much faster¹. Oil from the scalp clumps these dead skin cells together and causes “white flakes”. There can be many causes for dandruff such as dry scalp, poor hygiene and diet, and allergy to certain hair products¹. It is also commonly caused by infection with overactive fungus Malassezia globosa. Malassezia feeds on oil released from oil glands on your head and releases something called arachidonic acid (a fatty acid) causing inflammation and abnormal shedding of skin cells¹.

Although there are many products and home remedies out there recommended for dandruff, Nizoral Shampoo is often thought of as the first-line of treatment for this condition. This leads to our introduction of Nizoral which contains an effective anti-fungal ingredient: ketoconazole.

What Is Nizoral?

Nizoral Anti-Dandruff Shampoo can be found easily at your local pharmacy. In Canada, this medicated shampoo is indicated for prevention and treatment of fungal infections of the skin including dandruff and seborrheic dermatitis¹. Using the medication can relieve flaking, scaling and itching associated with dandruff¹. It is used just like a normal shampoo, except that after applying the shampoo on the scalp, you must leave it on for another 5 minutes before rinsing it out. It should be used 2-4 times a week for 4 weeks, and then once every 1-2 weeks after improvement, to see the overall effect¹.  It can also be used in addition to regular shampoo. Although it has a highly effective ingredient for dandruff and is quite convenient to use, it is a little pricey compared to other medicated shampoos in the market.

How Does Nizoral Work?

Nizoral shampoo treats a common type of dandruff caused by a fungal infection.  The active ingredient ketoconazole is an antifungal agent and found in a concentration of 1% over-the-counter (you can buy without a prescription) and in a concentration of 2% as a prescription. It works by targeting the cell membrane of fungi². For anyone interested – ketoconazole blocks the creation of an essential component of fungal cell membrane³, making holes and disrupts the integrity of the cell membrane of fungi. This leads to the leaking out of the essential constituents of fungal cells, eventually causing it to die.

What Does The Evidence Say?

Most of the clinical trials that have been done with the prescription strength (2% ketoconazole) and not with the over-the-counter strength (1% ketoconazole).  In a small study comparing 1% with 2% ketoconazole, the 2% was better at reducing the flakiness and density of the fungus (Malassezia) ⁴.  Depending on the severity of your dandruff (or seborrheic dermatitis), you may want to opt for a prescription strength if the 1% isn’t helping enough.

A study comparing ketoconazole 2% (prescription strength) and zinc pyrithione (another anti-dandruff ingredient found in shampoos like Head and Shoulders) found both ingredients showed improvement but there was a greater improvement in the group using ketoconazole 2%⁵.  The ketoconazole 2% worked slightly better to improve how severe the dandruff was and the recurrence of the condition (both for severe dandruff and seborrheic dermatitis).

Another study compared ketoconazole 2% and selenium sulfide 2.5% (another anti-dandruff ingredient found in shampoos like Selsun Blue) found both ingredients to effective to in reducing dandruff, irritation and itch⁶.  Although both were effective, it appears that ketoconazole is better tolerated because the main adverse events reported came from the group using selenium sulfide.  Side effects reported with selenium sulfide 2.5%  included burning sensation on scalp, lightening/bleaching of hair color, psoriasis, orange staining of the scalp and chemical taste while being shampooed⁵. This result suggests that ketoconazole 2% shampoo may be better tolerated than selenium sulfide shampoo.

Is Nizoral Safe To Use?

Before using this product, you must consider a few things⁷:

• Do not use if you have an allergy to ketoconazole or any of the other ingredients (such as sodium laureth sulphate)
• It should not be used by children under the age of 12.
• If you are pregnant or breast-feeding, discuss this product with your pharmacist or physician as there are no well-controlled studies to confirm that this product is safe during pregnancy or breast-feeding.
• If you are on other chronic medication (or using other products for your scalp) check with your pharmacist or physician to make sure there are no drug interactions.

What Are Some Possible Side Effects With Nizoral Shampoo?

Possible side effects include^1,7:

• Dryness
• Oiliness of hair and scalp
• Irritation
• Acne
• Alopecia

What Are Other Ways To Get Rid Of Dandruff?

There are quite a few different methods try (with or without medicated shampoo like Nizoral) to manage the dandruff¹.

• Shampoo regularly: daily shampooing may be the easiest way to get rid of dandruff¹. Use a regular shampoo at least 3 times a week to help eliminate dirt and oil, and to ease itching (shampoos with surfactants and detergents may be better able to remove the scales).
• Avoid scratching your scalp: resist from scratching the itchy patches on your head, as it may damage your scalp.
• Wash your hair after exercising or using cosmetic hair products: this is important since sweat and oil can irritate the scalp and speed up the flaking of skin cells.
• Use a cool air humidifier or hair moisturizer: dandruff may improve in a moist environment.

Bottom Line

Nizoral 1% Shampoo is a commonly used product and many studies seem to support the effectiveness and safety of ketoconazole in treating dandruff.  If you are seeing some benefit but not enough, you may want opt for the prescription strength of 2%. However, as with any other medications, it is always recommended to consult a physician or a pharmacist if you have any questions or uncertainties.

Authors:

Hayoung An, Jiyoung Lim, Minyoung Kim, Kyesun Kim, Seulki Shin, Hyowon Yoon, BSc. Pharm Candidates
Faculty of Pharmacy and Pharmaceutical Sciences
University of Alberta

Corresponding Author: 

Aliya Kassamali, B.Sc.Pharm, PharmD

Edited and Reviewed by the Health Aisle Team 

Last Updated: September 30, 2019

References
1. Canadian Pharmacists Association. (2013). Therapeutic Choices For Minor Ailments. Chapter 58 Dandruff and Seborrhea: 568-580.
2. Piérard‐Franchimont, C., Goffin, V., Henry, F., et al. (2002). Nudging hair shedding by antidandruff shampoos. A comparison of 1% ketoconazole, 1% piroctone olamine and 1% zinc pyrithione formulations. International Journal of Cosmetic Science, 24(5), 249-256.
3. James R. S., Yvonne M. D., & Thomas L. D, Jr. (n.d.) Dandruff and Seborrheic Dermatitis: A Head Scratcher. Retrieved from http://www.pgscience.com/files/pdf/Dr._Thomas_Dawson/TRI_book_chapter_Ch12_Dandruff.pdf
4. Piérard-Franchimont C, Piérard G, E, Arrese J, E, De Doncker P. (2001). Effect of Ketoconazole 1% and 2% Shampoos on Severe Dandruff and Seborrhoeic Dermatitis: Clinical, Squamometric and Mycological Assessments. Dermatology. 202:171-176.
5. Piérard-Franchimont C, Goffin V, Decroix J, Piérard G, E. (2002). A Multicenter Randomized Trial of Ketoconazole 2% and Zinc Pyrithione 1% Shampoos in Severe Dandruff and Seborrheic Dermatitis. Skin Pharmacol Appl Skin Physiol. 15:434-441.
6. Danby, F., Maddin, W., Margesson, L., & Rosenthal, D. (1993). A randomized, double-blind, placebo-controlled trial of ketoconazole 2% shampoo versus selenium sulfide 2.5% shampoo in the treatment of moderate to severe dandruff. Journal Of The American Academy Of Dermatology, 29(6), 1008-1012.
7. e-CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2007 [updated 2010 Oct 19; cited 2014 Apr 12].  Nizoral

. Available from: http://www.e-cps.ca. Also available in paper copy from the publisher