Abstract Background Acne scars are a source of cosmetic concern for most patients. Objective To compare the clinical efficacy and safety of topical botulinum toxin A(BTX-A) application immediately after microneedling (Mn) versus Mn with saline in the treatment of atrophic acne scars. Patients and Methods Forty- patients with atrophic acne scars (rolling, boxcar, and mixed types) were enrolled in a split-face study; One side of each patient’s face was subjected to microneedling followed by topically diluted botulinum toxin (side A) and the other side was treated by (microneedling +saline) (side B) for 2sessions 2 weeks apart. The evaluation was done at baseline, 2 and 4 weeks after the session. Follow-up was 6 months. The assessments included blinded clinical assessment and subjective satisfaction. Results At 4 weeks, acne scars in (side A) showed an overall improvement in 70% versus 0% of side B (P<0.0001). A statistically highly significant reduction of global severity scarring grading occurred in (side A) (P=0.0008). Patient satisfaction was higher in (side A) (P<0.0001). No serious side effects were noticed. Conclusions Microneedling delivery for botulinum toxin -A could be a simple, safe, and innovative modality in improving the appearance and decrease the depth of atrophic acne scars.