Advances in imaging for systemic sclerosis

SSc is the rheumatic disease with the highest individual mortality rate and is associated with substantial morbidity that severely affects quality of life. Organ fibrosis is a major contributor to irreversible damage in SSc, whereas early inflammatory manifestations largely reflect disease activity and may still respond to early immunomodulatory treatment. New imaging modalities, as well as novel applications of established techniques-such as lung US or improved US assessment of synovial involvement-offer promising opportunities to objectively distinguish activity i.e. early inflammation and early fibrosis from damage (i.e. late irreversible fixed vasculopathy or fibrosis) at the organ level. Differentiating these processes is essential for refining the therapeutic window of opportunity in this rare but devastating disease. This narrative review aims to provide an up-to-date overview of available and emerging imaging tools that may help discriminate activity from damage across organ systems involved in SSc, with a specific focus on early fibrotic and inflammatory manifestations.