Background Cutaneous vascular lesions (VLs) are benign or malignant processes involving blood and/or lymphatic vessels, usually readily diagnosed with dermoscopy. However, cases showing unclear clinical/dermoscopic findings may require further investigations. Line‐field confocal optical coherence tomography (LC‐OCT) is a new, non‐invasive imaging technique displaying high resolution and deep penetration. The aim of this study was to describe the LC‐OCT features of the most common benign and malignant VLs and to correlate them with histopathological substrates. Methods Clinical, dermoscopic, LC‐OCT and histopathological images of VLs were retrospectively collected. Detailed LC‐OCT description and histopathological correlations were produced for different types of VLs. Results The study included 71 VLs belonging to 50 caucasian patients 31 (62%) females; median age 56.8 (30–83) years study lesions included 25 cherry haemangiomas, 15 angiokeratomas, 10 thrombosed haemangiomas, six pyogenic granulomas, five venous lakes, four targetoid haemosiderotic haemangiomas, four Kaposi's sarcomas and two extraungual glomus tumours. LC‐OCT detected increased dermal vascularity, assuming different size and shape according to the particular type of VLs. LC‐OCT criteria correlated well to established histopathologic findings. Conclusion The results of our preliminary observations indicate that in vivo evaluation with LC‐OCT may provide practical clues for the identification of the vascular nature of a lesion and its differential diagnosis.