Introduction <p>Visible signs of skin aging, including enlarged pores, rosacea, and melasma, are often difficult to treat due to their multifactorial etiology. Most conventional therapies offer only temporary improvement and require ongoing maintenance. Exosome-based treatments present a regenerative approach that targets key biological dysfunctions associated with aging skin.</p> Case report <p>A healthy female in her late 40s with Grade 3 pore enlargement, Subtype I rosacea, and epidermal-type melasma (MASI score 10) underwent two sessions of topical exosome application following superficial microneedling at 0.3 mm depth, performed on Day 1 and Day 21. Clinical progress was documented at baseline, 3 weeks, 5.5 months, and 21 months using standardized photography, AI-assisted 3D imaging, and validated scales (MASI, CEA, GAIS). Progressive, multidimensional improvements were observed: pore size reduced by up to 41%, erythema by 42%, and melanin deposition by 31% at 5.5 months. These effects were largely sustained at 21 months. Surface roughness metrics (Ra, Rq, Rmax, Rz, Rp, Rv) also improved significantly.</p> Discussion <p>The results indicate that topical exosome therapy combined with superficial microneedling promotes lasting improvements in key clinical markers of skin aging. The sustained effects over 21 months suggest biological remodeling rather than transient cosmetic correction. No adverse events occurred throughout the follow-up period, confirming the safety and tolerability of the protocol.</p> Conclusion <p>A short protocol of topical exosomes with superficial microneedling achieved durable improvements in pore size, redness, and pigmentation that persisted for nearly two years without retreatment. These findings support its potential as a low-risk, regenerative modality for long-term facial rejuvenation.</p>