This chapter presents the specific capillaroscopic abnormalities, observable by nailfold (video) capillaroscopy (NVC) in systemic sclerosis (SSc). In this way it will describe the validated SSc NVC patterns (“Early” “Active” “Late”), elaborate on the earliest signals of microvessel damage (“Very Early”) and explain the progressive evolution up to the most advanced and severe disruption of the microvasculature. The driving mechanism that follows the immune mediated damage of endothelial cells (ECs) and the development of dermal fibrosis, represented by the endothelial-to-mesenchymal cells transition (EndoMT) will be discussed. Also the further role of the innate immunity concerning macrophage activation (M1) and their polarisation into profibrotic M2 will be hinted at. The use of the terminology “scleroderma-like” will be explained. Studies attesting an association between clinical SSc manifestations and the progression of the SSc NVC pattern’s severity will be discussed. Lastly, the studies that have used NVC to look at the structural effects of vasodilators, immunosuppressive drugs and also the antifibrotic tyrosine kinase inhibitor (nintedanib) on micovascular status will be elaborated on.