Background: Managing patients with severe diabetic neuropathy is a great challenge, many lines of treatment are available but there are many patients that cannot tolerate large doses of these medications or not responding or contraindicated to use these lines. Recent experimental evidence suggests that botulinum toxin type A (BTX-A) may have role in management of neuropathic pain. Methods:42 patients with diabetes(22 patients injected Botox and 20 patients placebo) were enrolled in this study. Patients were assessed using VAS and PSQI scale at 0,1,4,12 weeks. Results: significant reduction in VAS 1,4- and 12-weeks post injection in patients injected with Botox in comparison to patients injected with placebo p (.047,.001 and .000) respectively. No significant improvement in PSQI in patient injected with Botox as compared to patients injected with placebo. Conclusion: Botulinum Toxin (A) is effective in sever diabetic neuropathy and may be an alternative way in management of severe diabetic neuropathy.