Background The metastatic involvement of regional lymph nodes is the most important prognostic factor for overall survival of skin cancer patients. The sonographic technique of freehand real‐time tissue elastography (RTE), which displays tissue rigidity as a colour overlay of the tissue image, was developed. Objective Our purpose was to evaluate the benefit of RTE for detecting lymph node metastases of skin cancer non‐invasively before operation. Methods We first selected lymph nodes of skin cancer patients which had already been diagnosed by biopsy as being reactive or metastatic, and then retrospectively collected images of RTE and B‐mode and colour Doppler ultrasound on those lymph nodes performed preoperatively. Twenty‐one lymph nodes from 12 patients with squamous cell carcinoma (SCC), 23 lymph nodes from 14 patients with malignant melanoma (MM) and 14 lymph nodes from six patients with extramammary Paget disease (Paget) were investigated. Elastographic images were assessed on a scale of one to four according to the percentage of high elasticity (hard) area (HEA) in the lymph node. Results In all three skin cancers, lymph nodes evaluated as grade 3 or 4 by RTE were metastatic. All lymph nodes evaluated as grade 1 or 2 by RTE were reactive in SCC, whereas some lymph nodes evaluated as grade 1 or 2 were metastatic in MM and Paget. Conclusion Real‐time tissue elastography may aid in distinguishing reactive lymph nodes from metastatic ones especially in SCC.