Decoding vascular dysfunction in systemic sclerosis: from endothelial damage to clinical implications.

Purpose of review: This review explores the evolving understanding of vascular dysfunction in systemic sclerosis (SSc), from early endothelial injury to clinical manifestations and emerging therapeutic strategies.

Recent findings: Endothelial cell (EC) injury, senescence, and endothelial-to-mesenchymal transition are central to SSc vasculopathy. Single-cell and spatial omics have revealed distinct EC subtypes and dysregulated pathways, including interferon signaling and chromatin remodeling. Immune-mediated damage, viral triggers, and autoantibodies contribute to vascular pathology. Clinically, complications such as Raynaud's phenomenon, digital ulcers, pulmonary arterial hypertension, and renal crisis drive morbidity and healthcare burden. Diagnostic tools such as nailfold capillaroscopy enable early detection of microvascular changes. Novel therapies including CAR-T therapy, JAK inhibitors, and complement blockade, are under investigation.

Summary: Vascular dysfunction is a hallmark of SSc and a key driver of disease progression. Advances in molecular profiling and imaging have improved our understanding of its mechanisms and opened new avenues for targeted intervention. Early diagnosis, biomarker-guided care, and multidisciplinary management are essential to improving outcomes.