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Summary: Background: Monitoring of disease activity in sclerosing dermatoses (SD) can be challenging and tools to support clinical decision‐making are lacking. Aim: To analyse the impact of high‐frequency ultrasonography (HFUS) on the clinical management of SD and to describe the US characteristics of disease activity. Methods: This was a cohort study of patients with various SD [morphoea, systemic sclerosis (SS) and chronic graft‐versus‐host disease (cGvHD)] who underwent HFUS between January 2017 and August 2019. HFUS criteria for diagnosing active SD were increased Doppler vascularity and/or meeting all B‐mode greyscale US signs of activity. Discordance in SD activity between HFUS and clinical examination was evaluated at the time of the first US assessment. Changes in patient management were instituted after HFUS were recorded. Results: In total, 72 patients (31 with morphoea, 19 with SS and 22 with cGvHD), who underwent 163 HFUS sessions in total, were included. All HFUS‐active morphoea lesions exhibited increased vascularity, and all HFUS‐active SS exhibited dermal thickening and dermal hypoechogenicity. HFUS‐active cGvHD displayed increased dermal thickness and loss of definition of the dermal–hypodermal junction, and there were signs of panniculitis in 80% of cases and of increased vascularity in 70%. Discordance in disease activity between clinical and HFUS evaluation was found in 17 (23.6%) patients. Changes in clinical management after HFUS were made for 14 (19.4%) patients: treatment discontinuation for 6 patients (42.9%), treatment initiation for 5 (35.7%), medication change for 2 (14.3%) and skin biopsy taken for 1 (7.1%). Conclusion: HFUS seems an efficacious support tool in the monitoring of SD activity with a notable impact on clinical management. Further studies are warranted to evaluate the impact of HFUS‐supported management changes on SD outcomes. [ABSTRACT FROM AUTHOR]