Introduction and Aim: Imaging evaluation of the rheumatoid arthritis and systemic sclerosis represents a significant part in disease evaluation and follow up. However, it had many limitations and new tools are introduced continuously. The current work aimed to compare ultrasound characteristics of the hand involvement in systemic sclerosis (SSc) and rheumatoid arthritis (RA). Patients and methods: The study included 30 SSc and 40 RA patients. All were evaluated by the full history taking, detailed clinical examination, disease activity scores and the health assessment questionnaires were completed. All necessary laboratory investigations were performed. Finally, radiological examination (plain X-rays and ultrasound for joints of hands and wrist) was performed. Results: Patient age ranged from 22 to 58 years, and RA patients were significantly older, with female sex predominance. SSc was of diffuse (30%) and (70%) were of limited type. The disease activity of RA ranged from 2 to 9, while disease activity of SSc ranged between 1.3 to 3.5. In the SSc group, 56.7% had active disease compared to 40% in RA groups. Patients in the SSc group had a degree of disability, while 82.5% of patients in the RA group had mild- to- moderate disability. Ultrasound examination revealed that, synovitis was significantly increased in RA when compared to the SSc group (55.0% vs 23.3%). The sclerosing pattern of tenosynovitis was significantly increased in SSc than the RA group (92.3% vs 0.0% respectively). Results of ultrasound completely coincides with results of MRI. Finally, there was statistically significant, moderate, proportional correlation between ultrasound and each of erythrocyte sedimentation rate (ESR), and disease activity scores. Conclusion: Ultrasound hand examination in scleroderma and RA is more accurate than separate clinical or X-ray examinations. However, it could not completely substitute clinical examination. But it is a suitable add on especially in detection of early disease activity.