Objective: Prolonged exposure (PE) is an evidence-based psychotherapy for posttraumatic stress disorder (PTSD) but there is limited research with active-duty military populations. Virtual reality exposure (VRE) has shown promise but randomized trials are needed to evaluate efficacy relative to existing standards of care. This study evaluated the efficacy of VRE and PE for active duty soldiers with PTSD from deployments to Iraq and Afghanistan. Method: Active-duty soldiers (N = 162) were randomized to 10-sessions of PE, VRE, or a minimal attention waitlist (WL). Blinded assessors evaluated symptoms at baseline, halfway through treatment, at posttreatment, and at 3- and 6-month follow-ups using the Clinician Administered PTSD Scale (CAPS). Results: Intent-to-treat analyses found that both PE and VRE resulted in significant reductions in PTSD symptoms relative to those in the WL. The majority of patients demonstrated reliable change in PTSD symptoms. There was no difference between PE and VRE regarding treatment drop out before completing 10 sessions (44 and 41% for VRE and PE, respectively). Contrary to hypotheses, analyses at posttreatment did not show that VRE was superior to PE. Post hoc analyses found that PE resulted in significantly greater symptom reductions than VRE at 3- and 6-month follow-up. Both treatments significantly reduced self-reported stigma. Conclusions: PE is an efficacious treatment for active-duty Army soldiers with PTSD from deployments to Iraq or Afghanistan. Results extend previous evidence supporting the efficacy of PE to active-duty military personnel and raise important questions for future research on VRE.