• Stem cell-derived exosomes promote oligodendrocyte repair through immunomodulatory mechanisms.
• There is a deep interaction between the exosome functional network and myelin homeostasis.
• Engineered exosome delivery systems with targeting peptide modification and functional molecule loading represent a new frontier for precision therapy.
• Exosome-based cell-free therapy offers a novel paradigm for treating neurodegenerative and demyelinating diseases by modulating the inflammatory microenvironment.