Background <p>Tranexamic acid (TXA) has been explored as a potential treatment for melasma, and microneedling (MN) enhances transcutaneous drug delivery. To evaluate the clinical efficacy, patient satisfaction, and safety of microneedling combined with TXA (MN + TXA) in treating melasma compared to alternative treatment modalities.</p> Methods <p>A systematic review and meta-analysis were conducted following PRISMA guidelines. Clinical improvement, patient satisfaction, and adverse events were analyzed using standardized mean differences (SMD) with 95% confidence intervals (CI). The risk of bias was assessed using the RoB 2.0 and ROBINS-I tools.</p> Results <p>MN + TXA showed no significant improvement over other treatments in overall clinical outcomes. However, subgroup analysis revealed MN + TXA was significantly more effective than MN alone. Patient satisfaction did not significantly differ between MN + TXA and other treatments. The incidence of adverse events was similar across treatment groups.</p> Conclusion <p>Compared to other therapies, MN+TXA may be considered a potential option for melasma management. Future large-scale, standardized, multicenter trials directly are essential to confirm its efficacy, safety, and clinical utility.</p> Level of Evidence I <p>This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors <a href="http://www.springer.com/00266">www.springer.com/00266</a>.</p>