Background: Telemedicine technology holds great promise for dermatologic health care delivery. However, the clinical outcomes of digital image consultations (teledermatology) must be compared with traditional clinic-based consultations. Objective: Our purpose was to assess and compare the reliability and accuracy of dermatologists’ diagnoses and management recommendations for clinic-based and digital image consultations. Methods: One hundred sixty-eight lesions found among 129 patients were independently examined by 2 clinic-based dermatologists and 3 different digital image dermatologist consultants. The reliability and accuracy of the examiners’ diagnoses and the reliability of their management recommendations were compared. Results: Proportion agreement among clinic-based examiners for their single most likely diagnosis was 0.54 (95% confidence interval [CI], 0.46-0.61) and was 0.92 (95% CI, 0.88-0.96) when ratings included differential diagnoses. Digital image consultants provided diagnoses that were comparably reliable to the clinic-based examiners. Agreement on management recommendations was variable. Digital image and clinic-based consultants displayed similar diagnostic accuracy. Conclusion: Digital image consultations result in reliable and accurate diagnostic outcomes when compared with traditional clinic-based consultations. (J Am Acad Dermatol 1999;41:693-702.)