This study evaluates the efficacy and safety of the combined microneedling (CMNT) with minoxidil versus minoxidil monotherapy for the treatment of androgenetic alopecia (AGA), with a focus on the impact of microneedling parameters on treatment outcomes. We conducted a systematic review and meta-analysis (PROSPERO: CRD42024594487) of randomized controlled trials (RCTs) comparing CMNT versus minoxidil alone for AGA, following PRISMA guidelines. A comprehensive search across six databases was performed up to September 8, 2024. We identified 12 RCTs involving 631 AGA patients, with a total of 11 RCTs included in the meta-analyses. CMNT significantly improved hair count compared to minoxidil monotherapy (SMD 1.32, 95% CI 0.73-1.92, p <
0.01), with substantial heterogeneity (I² = 88%, p <
0.01). Subgroup analyses indicated no significant effect of microneedling (MN) depth (≤ 1 mm vs. >
1 mm), duration (≤ 12 weeks vs. >
12 weeks), or technique(device) (electrodynamic vs. rolling) on hair count outcomes. Additionally, A meta-analysis of six RCTs demonstrated a significant improvement in hair diameter with CMNT (SMD 0.34, 95% CI 0.11-0.58
p <
0.01), with no observed heterogeneity (I² = 0%). Investigators and patient's self-assessment scores were also improved. Adverse events were more frequent with CMNT (74 vs. 59 events), however they were generally considered mild or self-limiting. CMNT significantly enhances hair count and diameter in AGA patients with mild adverse events. MN parameters including depth, duration, and technique variations did not significantly affect hair count outcome, suggesting microneedling as a promising adjunctive AGA treatment.