Keratinocyte skin cancers (KC), including basal cell carcinoma (BCC) and the spectrum of squamous cell carcinoma (SCC), represent the most common malignancies worldwide. Accurate diagnosis and margin assessment are critical for optimal treatment but remain challenging when relying solely on clinical and dermoscopic evaluation. Reflectance confocal microscopy (RCM) offers high-resolution, noninvasive imaging of skin architecture at near-histological levels, potentially improving diagnostic precision and reducing the need for (re)biopsies.To evaluate the current diagnostic criteria, diagnostic utility, advantages, and limitations of confocal microscopy in the assessment of nonmelanoma skin cancer (NMSC).A narrative review of recent literature and current guidelines was conducted, focusing on RCM for the detection, characterization, and monitoring of BCC and KC. Key diagnostic criteria, imaging protocols, and clinical applications were analyzed, including preoperative mapping, differentiation from benign lesions, and follow-up after treatment.RCM provides real-time visualization of tumor architecture, cellular morphology, and vascular patterns, facilitating the identification of hallmark features such as basaloid tumor islands in BCC and keratinocyte atypia in SCC. Studies report improved diagnostic accuracy and reduced rates of unnecessary excisions. Limitations include restricted imaging depth and the requirement for operator expertise.RCM represents a powerful adjunct to conventional diagnostic methods for NMSC. Its ability to deliver high-resolution, noninvasive imaging enhances diagnostic confidence, supports surgical planning, and aids in treatment monitoring, ultimately improving patient care. Combining multiple noninvasive techniques with proper training is key to enhancing this approach and promoting its routine clinical use.