The fretting wear behavior of Zr alloy cladding tube under mixed fretting regime in a high-temperature pressurized water was investigated. The main wear mechanism is adhesive wear, with characters of small-scale delamination at the center of worn area and serious delamination on the worn edge. A long crack throughout the worn area and other cracks propagated towards the substrate are observed. The cross-sectional microstructure of worn area can be divided into a thick third-body layer, thin inner oxide layer and thick tribologically transformed structure layer, and their formation mechanisms are analyzed in detail. Finally, the mixed fretting regime process and the microstructural evolution during fretting wear are discussed.