Purpose <p>To report the clinical course and nailfold capillaroscopic changes in a patient with polycythemia vera (PV) and acrocyanosis, underscoring the potential of ruxolitinib to modulate microvascular dysfunction associated with myeloproliferative neoplasms.</p> Methods <p>We present the case of a 78-year-old woman with PV who developed pronounced acrocyanosis and abnormal nailfold capillaroscopic findings during treatment with hydroxyurea. Due to suboptimal symptom control and hematological side effects, the therapy was switched to ruxolitinib. Clinical assessments and nailfold capillaroscopy were conducted before and after the therapeutic change.</p> Results <p>Following the initiation of ruxolitinib, the patient experienced marked clinical improvement, including resolution of acrocyanosis and normalization of hematologic parameters. Follow-up capillaroscopy revealed a significant reduction in microvascular abnormalities, with restored architectural organization and only mild residual capillary tortuosity.</p> Conclusion <p>Ruxolitinib may offer dual therapeutic advantages in PV by effectively managing the hematologic burden of disease and improving microvascular symptoms such as acrocyanosis. Nailfold capillaroscopy may serve as a valuable non-invasive tool for assessing and monitoring microcirculatory involvement in patients with myeloproliferative neoplasms.</p>