Abstract Background: Combination therapies have reported to augment the repigmentation in vitiligo. Microneedling (Mn) facilitates drug delivery across the skin barrier. Objective: To evaluate and compare the efficacy and safety of Mn combined with tacrolimus vs Mn alone or tacrolimus 0.1% ointment for treatment of localized and stable vitiligo. Patients and Method: Ninety patients with vitiligo were randomized into three groups: group I received microneedling with tacrolimus, group II microneedling only both at 2 weeks interval for twelve sessions, and group III applied tacrolimus ointment 0.1% twice daily for 6 months. Skin biopsies were taken at baseline and after treatment. Results: The overall improvement (76.6%) was significantly higher in the combined group compared with other groups. Repigmentation was excellent in 66.6 of group I vs 33.3% in the other two groups (P .03). A highly significant improvement of the extremities was observed in the combined group than in the other groups (P < .001). A fewer number of sessions have reported in the combined group (I) than in the microneedling group (II; P < .001). Immunohistochemical results showed a significantly higher expression of HMB-45 in group I than in other two groups (P .04). Side effects were mild and tolerable in all groups. Conclusion: The combination group has shown promising results over the other two