Reflectance confocal microscopy (RCM) is a non-invasive imaging tool utilized for in vivo visualization of the skin. It has been extensively studied for use in evaluation of equivocal cutaneous neoplasms to decrease the biopsy of benign lesions. Furthermore, its applications are broadening to include pre-surgical cancer margin mapping, tumor recurrence surveillance, monitoring of ablative and non-invasive therapies and stratification of inflammatory disorders. With the approval of category I current procedural terminology reimbursement codes for RCM image acquisition and interpretation, use of this technology has been increasingly adopted by dermatologists. This review highlights basic terminology, principles, clinical applications, limitations and practical considerations in the clinical use of RCM technology.