Minority and low-income patients disproportionately experience dermatologic access challenges. Store-and-forward (SAF) teledermatology has emerged as a model of care delivery that may improve access. We sought to evaluate patterns of utilization and overall impact after SAF teledermatology implementation in a safety-net health care system. We performed a retrospective review of 3,285 teledermatology consultations from 2014 to 2017 in an urban academic safety-net health care system. A total of 1,680 (51.2%) patients were referred for inflammatory/rash conditions and 967 (29.5%) for skin lesions. The teledermatologist recommended in-person evaluation in 1,199 encounters (36.5%). Median wait time for a subsequent appointment was 36 days (range 0-244 days). Of subsequent in-clinic visits, 237 patients (26.4%) underwent skin biopsy. No-show rate after referral was 11.8%. In comparison, median wait time for dermatology appointment through standard referral was 64 days, with a no-show rate of 18.6%. Biopsy rate of patients referred via teledermatology was 26.4%, in comparison to a rate of 10.9% of patients referred directly from primary care provider. Implementation of SAF teledermatology in a safety-net health system resulted in avoidance of 63.5% potential dermatology visits. Consultation typically resulted in a change in suspected diagnosis or management plan. Rates of concordance between teledermatology consults and in-person evaluations were high. Median wait time was reduced by almost half, no-show rate was reduced ∼37%, and biopsy rate was more than double for teledermatology patients compared with standard referral. These findings suggest that SAF teledermatology may improve access to high-quality dermatologic care and increase clinic efficiencies for patients in safety-net health care systems.