The objective of the present work was to investigate the effects of 3 combinatorial techniques (microneedle (MN), electroporation (EP), and sonophoresis (SN)) on the in vitro skin permeation of the hydrophilic macromolecular compound fluorescein isothiocyanate-dextran (FD-4; molecular weight (MW) 4.4 kDa). Assessment of the in vitro skin permeation of FD-4 was performed in porcine skin. MN, EP, and SN were used as physical enhancement methods, given the potential of their various mechanisms. The total cumulative amount of FD-4 that permeated through treated skin using 2 or 3 combined methods, i.e., MN EP, MN SN, EP SN, and MN EP SN, was investigated. Microconduits created by MN alone and in combination with the other techniques were observed under confocal laser scanning microscopy (CLSM). The histology of the treated skin was examined. In vitro skin permeation experiments revealed that the total cumulative amount of FD-4 that permeated porcine skin using 3 combined techniques (MN EP SN) was greater than the amount observed using a single method or 2 combinations (MN EP, MN SN, SN EP). The histological images indicate no noticeable damage in the skin treated with all of the enhancement methods. These results suggest that MN EP SN may serve as a potentially effective combination strategy to transdermally deliver various hydrophilic macromolecules without causing structural alterations or skin damage.Key words microneedle; electroporation; sonophoresis; hydrophilic macromolecule; fluorescein isothiocyanate-dextran Skin is the largest organ in our bodies, covering an area of approximately 2 m 2 and providing contact between our bodies and the external environment. The main function of skin is to act as a barrier to prevent the loss of tissue water and the entrance of foreign molecules. 1) The barrier properties of skin are attributed to the outermost layer, the stratum corneum (SC), which is highly hydrophobic. Although SC is 10-20 µm thick, it only allows small, potent lipophilic drugs to permeate the skin. Most hydrophilic macromolecules, such as peptides and proteins, are unable to permeate passively. Therefore, enhancement techniques are required to assist in the transport of such macromolecules across the skin. 2,3) In this study, physical enhancement methods were intentionally highlighted, including microneedles (MN), electroporation (EP), and sonophoresis (SN). Although the implementation of these methods is different, they mutually seek to bypass or remove the SC. 4) MN are micron-sized needles that can breach the SC to create holes large enough for various molecules to pass through. The average needle lengths range from 100 to 1500 µm, which is long enough to pierce the SC and upper layers of viable epidermis. Nevertheless, the needles do not puncture the deeper dermis layer, where numerous nerve endings are located. In other words, the needles are minimally invasive and do not create a sense of pain. Interestingly, the needle holes are considerably larger than macromolecular sizes; therefore, the macromol...