Phosphodiesterase inhibitors (such as sildenafil) and endothelin receptor antagonist bosentan are effective for digital ulcer disease in systemic sclerosis (SSc-DU), and are endorsed in international treatment recommendations. Commissioning of high-cost drugs, such as bosentan, however differs across devolved nations of the United Kingdom (UK). We report a multi-centre service evaluation project to examine ‘real world’ management of SSc-DU, before and following the 2015 UK Scleroderma Study Group (UKSSG) guidance, across the South West (SW) UK and Wales. Results showed that iloprost and sildenafil use for SSc-DU was higher in patients in Wales prior to 2015. Between 2015-2017, sildenafil use for SSc-DU increased in SW England whilst remaining stable in Wales. Bosentan use for SSc-DU after 2015 in SW England increased, whilst remaining stable and proportionately lower in Wales. These findings demonstrate that differing commissioning guidance across devolved nations of UK seems to contribute to geographic variation in patient care.