The value of in vivo reflectance confocal microscopy (RCM) as a noninvasive adjunctive tool in dermatology has steadily advanced since its inception. With RCM, dermatologists can view horizontal sections of lesions in a resolution comparable to histology, observe dynamic processes in living skin, and monitor lesion evolution longitudinally. This article will compare RCM to dermoscopy and histology, review the general principles of the microscope, describe the findings seen on confocal images, and discuss the clinical applications of this noninvasive tool. Additionally, we describe a telepathology network dedicated to the transfer of confocal images to remote dermatopathologists for interpretation. Finally, we will discuss the adoption of RCM and the telepathology network in clinical practice.