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Lentigo maligna (LM) can be difficult to diagnose and recurrence is not uncommon. In vivo reflectance confocal microscopy (RCM) improves diagnostic accuracy of LM. LM can be difficult to discern from coexistent metal‐induced cutaneous hyperpigmentation (MICH). We are the first to describe three cases of LM associated with gold, silver, and metal oxide (from tattoos) and the RCM findings, respectively. The images obtained via RCM were analyzed by two RCM experts, and histopathology reviewed by a dermatopathologist. MICH under RCM appeared as intensely hyperreflective dots (when found freely) or clusters of variable sizes (when engulfed by macrophages) limited to the dermis. Dermal dendritic cells and melanophages were also found in association but distinct from the confluence of dendritic cells at the dermoepidermal junction observed in LM. We showed longitudinal changes within the dermis in MICH, not previously reported, where these hyperreflective dots congregate into clusters. RCM was able to distinguish the features of LM from MICH, delineate treatment margins, and monitor for recurrence. [ABSTRACT FROM AUTHOR]