Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

We read with interest the comments of M. Agrawal [1] regarding our recent article, a case of squamous cell carcinoma of the scalp after several synthetic hair grafts, because this means that the case report achieved our purpose to stimulate a fruitful clinical discussion on the topic [2]. Even so, we disagree with the prospective of the comments. We believe the aim and clinical message of the article were misunderstood.

The main purpose of a case report is to provide medical doctors an original point of view on the clinical features, investigation, and treatment of patients with unusual clinical problems. A case report may not provide statistical significance but should clearly illustrate uncommon cases and support junior doctors in their daily clinical activity. As a matter of fact, a case report represents an “alarm bell” for addressing misdiagnosed clinical conditions and for stimulating future investigations. In conclusion, each case is unique and conveys a precise message to the reader.

Indeed, the clinical messages of our report are that clinicians should not underestimate an ulcerative lesion on the scalp of a patient who has undergone multiple surgeries for artificial hair implantation, should not leave the patient to the care of nonlicensed medical doctors, and should consider diagnostic biopsies related to clinical suspicion and prompt therapeutic management fundamental to the treatment of a patient affected by cutaneous ulcerated lesion of the scalp.

We absolutely do not condemn synthetic hair grafting. Instead, we clearly stated in our discussion that the latency of degeneration (the chronic variant of Marjolin’s ulcer onset is reported to have an average lag of 35–46 years), the affected area, the typical clinical history characterized by repetitive local irritation and microtrauma, the occasional presence of bacterial sovra infection, and the prolonged actinic damage all may represent concomitant features strongly suggesting a clear pathophysiologic process that finally led to cancer degeneration [2–7].