Background: Melasma is a chronic pigmentary disorder that is often resistant to treatment and prone to recurrence. Microneedling may enhance the transepidermal delivery of topical tranexamic acid, potentially improving therapeutic outcomes. Objective: This study aimed to evaluate the clinical efficacy, dermoscopic changes, and safety of microneedling combined with topical tranexamic acid in female patients with melasma. Methods: This study included 27 adult females with bilateral symmetrical melasma. Patients received microneedling sessions combined with topical tranexamic acid at 2 week intervals for up to 6 sessions. Clinical severity was assessed using the modified Melasma Area and Severity Index (mMASI). Dermoscopic evaluation was performed at baseline and during follow up. Results: The mean mMASI score significantly decreased from 10.2 ± 1.6 before treatment to 4.2 ± 2 after therapy (p ≤ 0.001). Good improvement was achieved in 48.1% of patients and excellent improvement in 22.2%. Dermoscopic assessment showed significant lightening of lesion color (p = 0.013), with marked reduction in pseudonetwork pattern from 74.1% to 18.5% (p ≤ 0.001), arcuate pigmentation from 37% to 11.1% (p ≤ 0.001), and vascularity from 70.4% to 14.8% (p ≤ 0.001). Recurrence was observed in 11.1% during follow up. Conclusion: Microneedling combined with topical tranexamic acid is an effective and well tolerated treatment for female melasma, producing significant clinical and dermoscopic improvement with minimal adverse effects. Larger controlled studies with longer follow-up are recommended to confirm long term efficacy.