The rising burden of scabies in Italy: insights from a nationwide survey of dermatologists

Abstract

Background

Scabies is an increasingly relevant dermatological and public health issue, with rising case burdens reported in several European countries.

Objectives

To assess Italian dermatologists’ perceptions of recent scabies trends and current approaches to diagnosis, treatment, notification, and household-contact management.

Methods

A nationwide cross-sectional online survey was distributed to dermatologists practicing in Italy. The questionnaire investigated perceived epidemiological changes, diagnostic and notification practices, therapeutic choices, ivermectin use, retreatment, household-contact management, and perceived treatment failure. Descriptive, bivariate, and multivariable analyses were performed.

Results

Among 308 respondents, 94.2% perceived an increase in scabies cases during the previous 3–5 years, including 73.4% reporting a marked increase; 59.4% indicated that the increase involved all age groups. Clinical evaluation combined with dermoscopy was the most frequently reported diagnostic approach (88.0%), while 79.2% considered diagnosis often delayed. Combined topical and systemic therapy was the most commonly reported first-line approach (56.5%), and 81.8% perceived treatment failures, particularly with topical permethrin, as more frequent than in the past. Among the 306 respondents providing data on household-contact management, 83.3% reported systematically treating cohabitants. Significant differences emerged according to geographical area and workplace setting. In adjusted analyses, private practitioners were less likely to report systematic treatment of household contacts, whereas longer professional experience was associated with greater perception of increasing treatment failure.

Conclusions

Italian dermatologists perceive scabies as an increasingly frequent and clinically challenging condition. These findings support standardized management pathways integrating dermatologists, general practitioners, and public health services, with coordinated household-contact treatment and careful assessment of adherence and reinfestation before therapeutic escalation or attribution of perceived failure to resistance. Objective epidemiological and treatment-outcome studies remain necessary.

Introduction

Scabies is a contagious ectoparasitic skin infestation caused by Sarcoptes scabiei var. hominis and remains a relevant dermatological and public health concern worldwide. Although traditionally associated with overcrowding, poor hygiene, institutional settings, and socioeconomic vulnerability, it is increasingly recognized as a broader and re-emerging problem affecting heterogeneous populations and healthcare systems [1, 2]. Its burden extends beyond the individual patient, as delayed diagnosis, atypical clinical presentations, possible resistance or reduced response to first-line therapies, difficulty in accessing healthcare, and inadequate management can facilitate household transmission, community outbreaks, and recurrent infestations [3].

In recent years, multiple countries have reported a rising incidence of scabies, suggesting re-emergence in both endemic and non-endemic settings. Across Europe, available epidemiological data indicate an increasing trend over the last 10–20 years, especially in populations exposed to facilitating factors such as frequent travel, migration, precarious living conditions, and younger age [3–8]. In recognition of its global burden and under-recognition, the World Health Organization included scabies among Neglected Tropical Diseases in 2017 [1].

The apparent post-pandemic resurgence of scabies has further intensified clinical and epidemiological interest. Reported drivers include delayed access to care, prolonged household exposure during lockdowns, socioeconomic challenges, and disruptions in treatment pathways [9, 10]. In Italy, this pattern is reflected in regional data: in Lazio, incidence fell sharply at the onset of COVID-19 (− 79.6%) but then rose markedly (+ 143.4% in 2020–2021, + 142.3% in 2021–2022, + 170.3% in 2022–2023), accompanied by a substantial increase in outbreaks in long-term care facilities (+ 750% from 2020 to 2023) [10]. Similarly, in the area of Messina (Sicily), 288 cases were notified in 2020–2022 (30.8% of all cases reported from 2003 to 2022), with a median incidence of 11.3 ± 9.7 per 100,000 compared with 3.1 ± 6.1 in 2003–2017 [7].

Despite a growing body of literature on scabies epidemiology and treatment, less is known about how dermatologists perceive recent changes in scabies burden and how they manage diagnosis, first-line treatment, retreatment, notification, and household contacts in routine practice. Understanding these aspects is important in a rapidly evolving context characterized by post-pandemic pressures, possible therapeutic challenges, and increasing attention to public health implications.

Against this background, the present study aimed to investigate the experience and perceptions of dermatologists regarding recent trends in scabies in Italy through a nationwide survey. Specifically, the survey explored perceived changes in scabies frequency, age groups involved, diagnostic practices, reporting behavior, first-line therapeutic choices, use of systemic ivermectin, retreatment strategies, management of cohabitants, and perceptions of increasing therapeutic failure, particularly with permethrin.

Materials and methods

Study design and survey development

This cross-sectional, questionnaire-based survey was promoted by ADOI (Associazione Dermatologi-Venereologi Ospedalieri Italiani e della Sanità Pubblica) and AIDA (Associazione Italiana Dermatologi Ambulatoriali) to explore Italian dermatologists’ perceptions and clinical practices regarding scabies. The investigators developed a structured set of close-ended questions specifically for this study.

The questionnaire collected information on respondents’ professional characteristics (years of specialization, sex, geographical area of practice, and main workplace setting) and on perceived changes in the number of scabies cases over the previous 3–5 years, age groups most frequently involved, diagnostic methods, perceived diagnostic delay, notification practices, preferred first-line treatment, timing of retreatment, indications for systemic ivermectin, management of household contacts, and perception of therapeutic failure, particularly with topical permethrin. Most questions were single-answer multiple-choice, with selected items allowing multiple responses. The questionnaire was administered in Italian.

Survey administration and participant recruitment

The survey was administered online and disseminated to dermatologists practicing in Italy through professional mailing lists and social media channels. Participation was voluntary and not incentivized. Respondents were eligible if they were physicians with dermatological training or clinical activity in dermatology. The survey was anonymous, and no directly identifiable personal data were collected. Each submitted questionnaire was considered a unique observation.

Study outcomes

The primary variables of interest were diagnostic and therapeutic management strategies in relation to perceived changes in scabies incidence in clinical practice over the previous 3–5 years. Collected variables included: years of specialization in dermatology (< 10, 10–19, 20–29, ≥ 30 years); sex; geographical area of practice (Northern Italy, Central Italy, Southern Italy and Islands); main workplace setting; perceived trend in scabies cases; age groups in which the increase was most frequently observed; diagnostic procedures; perception of diagnostic delay; infectious disease notification; first-line therapeutic approach; timing of retreatment after the first treatment cycle; indications for systemic ivermectin; management and retreatment of household contacts; and perception of therapeutic failure, particularly with topical permethrin.

Statistical analysis

Categorical variables were summarized as absolute frequencies and percentages, calculated on the number of available responses for each item. Associations between categorical variables were assessed using chi-square or Fisher’s exact tests, as appropriate. To explore factors associated with selected clinically relevant outcomes, multivariable logistic regression models were fitted including years of specialization, sex, geographical area, and workplace setting as independent variables. A complete-case approach was used, p < 0.05 was considered statistically significant, and statistical analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria) [11].

Ethical considerations and privacy aspects

Participation in the survey was voluntary. Before accessing the questionnaire, respondents were informed about the study aims and the anonymous nature of data collection. No directly identifiable personal data, including name, email address, telephone number, or IP address, were collected. Electronic informed consent was obtained, and submission of the completed questionnaire was considered to indicate consent to participate and to the use of anonymized, aggregated data for research purposes. Given the anonymous, non-interventional design, formal ethics committee approval was considered not to be required according to applicable local regulations. The study was conducted in accordance with the Declaration of Helsinki.

Results

Respondent characteristics

A total of 308 dermatologists completed the survey. Nearly half had been specialists for ≥ 30 years (47.4%). Females accounted for 53.6% of the sample. Most participants were practicing in Northern Italy (45.8%), followed by Central Italy (30.8%) and Southern Italy/Islands (23.4%). Private practice/private clinics represented the most common workplace setting (55.8%), followed by Hospital/IRCCS (21.4%), ASL (12.3%), and University (3.2%). Detailed participant characteristics are summarized in Table 1.

Table 1.

Demographic and professional characteristics of respondents to the scabies survey

Domain	Category	n	%
Experience in dermatology	<10 years	37	12.0
	10–19 years	58	18.8
	20–29 years	67	21.8
	≥30 years	146	47.4
Sex	Female	165	53.6
	Male	143	46.4
Geographical area	Northern Italy	141	45.8
	Central Italy	95	30.8
	Southern Italy and Islands	72	23.4
Main workplace setting	Private practice/private clinic	172	55.8
	Hospital/IRCCS	66	21.4
	Local health service (ASL)	38	12.3
	Retired	17	5.5
	University	10	3.2
	Other	5	1.6

The table summarizes the distribution of participants according to years of experience in dermatology, sex, geographical area, and main workplace setting. Most respondents had ≥30 years of dermatological experience, with a balanced sex distribution, predominant representation from Northern Italy, and private practice/private clinics as the most frequently reported workplace setting

Epidemiological perception of scabies burden

Overall, 290/308 dermatologists (94.2%; 95% CI 91.0–96.3) reported an increase in scabies cases in clinical practice over the previous 3–5 years, including 226/308 (73.4%) reporting a marked increase and 64/308 (20.8%) a mild/moderate increase (Fig. 1). By contrast, 4.9% reported a stable trend, 0.6% a decrease, and 0.3% considered the question not relevant.

Fig. 1.

Perceived change in scabies incidence over the previous 3–5 years. Distribution of dermatologists’ responses regarding perceived changes in scabies cases in clinical practice. Most respondents reported an increase in cases, with the majority describing it as marked

Regarding the age groups most frequently involved, 183/308 (59.4%; 95% CI 53.8–64.8) indicated that the increase affected all age groups, whereas 86/308 (27.9%) selected adults, 22/308 (7.1%) older adults, and 17/308 (5.5%) the pediatric population.

Diagnostic approaches and notification practices

Clinical evaluation combined with dermoscopy was by far the most frequently reported diagnostic strategy (271/308, 88.0%; 95% CI 83.9–91.2), whereas clinical examination alone, clinical examination plus microscopic scraping, and entodermoscopy were rarely reported (Fig. 2).

Fig. 2.

Reported indications for oral ivermectin use in scabies management. Frequency of selected clinical scenarios considered appropriate for systemic ivermectin, including topical treatment failure, poor adherence to topical therapy, crusted scabies, and community outbreaks

A total of 244/308 dermatologists (79.2%; 95% CI 74.3–83.4) stated that the diagnosis of scabies is often delayed, 56/308 (18.2%) considered this to depend on the clinical context, and 8/308 (2.6%) reported that diagnostic delay is not frequent.

When asked whether they notify confirmed cases as infectious disease, 182/308 (59.1%) reported doing so always, 68/308 (22.1%) sometimes, 26/308 (8.4%) rarely, 10/308 (3.2%) never, and 22/308 (7.1%) stated that they did not know how to proceed or considered the process complicated. Overall, 250/308 (81.2%) reported notifying confirmed cases always or sometimes.

Therapeutic approaches and household management

The most frequently selected first-line therapeutic option was combined topical and systemic therapy, reported by 174/308 respondents (56.5%; 95% CI 50.9–61.9), including respondents who selected this option together with another treatment. After assigning each respondent to a single mutually exclusive category, the remaining responses included topical permethrin alone (59/308, 19.2%), benzyl benzoate alone (33/308, 10.7%), oral ivermectin alone (17/308, 5.5%), and sulfur-based ointment alone (3/308, 1.0%). A further 22/308 respondents (7.1%) selected other treatments or multiple non-combined regimens (Fig. 3).

Fig. 3.

First-line treatment preferences for scabies. Distribution of preferred first-line therapeutic approaches among surveyed dermatologists. Combined topical and systemic therapy was the most frequently reported option, followed by topical permethrin, benzyl benzoate, oral ivermectin, and sulfur-based ointments

After the first therapeutic cycle, 271/308 respondents (88.0%; 95% CI 83.9–91.2) reported that they always repeat treatment after 7 days, 22/308 (7.1%) after 14 days, 12/308 (3.9%) only in the case of symptom persistence, and 3/308 (1.0%) generally do not repeat treatment.

With regard to indications for systemic ivermectin, 212/308 respondents (68.8%) selected all the proposed scenarios. Of the remaining respondents, 88/308 (28.6%) selected one or more specific indications without selecting all the proposed scenarios, whereas 8/308 (2.6%) stated that they do not use ivermectin.

Finally, 252/308 dermatologists (81.8%; 95% CI 77.1–85.7) reported that they perceived therapeutic failures to have become more frequent, particularly with topical permethrin; 27/308 (8.8%) answered no and 29/308 (9.4%) were uncertain.

Data on household-contact management were available for 306 respondents. Among them, 255/306 (83.3%; 95% CI 78.7–87.0) reported that they systematically treat cohabitants, 29/306 (9.5%) treated them only if symptomatic, 21/306 (6.9%) indicated that this depended on the context, and 1/306 (0.3%) generally did not treat cohabitants.

Among the 306 respondents answering the question on retreatment of cohabitants, 182/306 (59.5%) repeated treatment systematically after 7 days, 10/306 (3.3%) after 14 days, 66/306 (21.6%) only in the case of symptom persistence, 45/306 (14.7%) generally did not repeat treatment, and 3/306 (1.0%) stated that they did not treat cohabitants.

Bivariate analyses

Geographical differences

The proportion of respondents reporting a marked increase in scabies cases differed significantly across Italian macro-areas (p = 0.006), increasing from 65.2% in Northern Italy to 76.8% in Central Italy and 84.7% in Southern Italy/Islands. The proportion of dermatologists who systematically treated household contacts also varied significantly by area (p = 0.010), being highest in the North (89.4%), intermediate in the South/Islands (83.3%), and lowest in Central Italy (74.2% among respondents with available data). No statistically significant geographical differences emerged for selection of combined therapy as first-line treatment (p = 0.252), for selecting all the proposed indications for ivermectin use (p = 0.339), for notification practices (p = 0.702), or for the perceived therapeutic failures to have become more frequent (p = 0.388).

Workplace setting differences

Across the four main workplace settings included in the comparative analysis, the proportion of respondents reporting a marked increase in cases did not differ significantly (p = 0.280). Workplace setting was significantly associated with first-line combined therapy, notification practices, and systematic treatment of household contacts, but not with reporting a marked increase in cases, ivermectin use, or perceived permethrin failure (Table 2).

Table 2.

Survey responses on epidemiological trends, diagnostic approaches, treatment practices, and management of scabies

Domain	Category	n	%
Perceived change in scabies cases	Marked increase	226	73.4
	Mild/moderate increase	64	20.8
	Stable	15	4.9
	Decreasing	2	0.6
	Not sure/not relevant	1	0.3
Age group in which the increase was most frequently observed	All age groups	183	59.4
	Adults	86	27.9
	Older adults	22	7.1
	Pediatric population	17	5.5
Most frequent diagnostic approach	Clinical examination + dermoscopy	271	88.0
	Clinical examination only	19	6.2
	Clinical examination + microscopic scraping	17	5.5
	Entodermoscopy	1	0.3
Is diagnosis often delayed?	Yes	244	79.2
	Depends on the context	56	18.2
	No	8	2.6
Notification of infectious disease after confirmed diagnosis	Yes, always	182	59.1
	Yes, sometimes	68	22.1
	Rarely	26	8.4
	Uncertain/how to proceed is difficult	22	7.1
	Never	10	3.2
Most frequent first-line treatment regimen	Combined topical and systemic therapy (selected alone or with other options)	174	56.5
	Topical permethrin alone	59	19.2
	Benzyl benzoate alone	33	10.7
	Oral ivermectin alone	17	5.5
	Sulfur-based ointment alone	3	1.0
	Other or multiple non-combined regimens	22	7.1
After the first treatment cycle, do you repeat treatment?	Yes, always after 7 days	271	88.0
	Yes, after 14 days	22	7.1
	Only if symptoms persist	12	3.9
	No, generally not	3	1.0
Preferred indications for systemic ivermectin	All proposed scenarios	212	68.8
	One or more specific indications, without selecting all proposed scenarios	88	28.6
	I do not use ivermectin	8	2.6
Do you systematically treat household contacts?	Yes, always	255	83.3
	Only if symptomatic	29	9.5
	Depends on the context	21	6.9
	No, generally not	1	0.3
If household contacts are treated, do you repeat treatment?	Yes, always after 7 days	182	59.5
	Yes, after 14 days	10	3.3
	Only if symptoms persist	66	21.6
	No, generally not	45	14.7
	Household contacts are not treated	3	1.0
More frequent perceived treatment failures than in the past, particularly with topical permethrin?	Yes	252	81.8
	No	27	8.8
	Not sure	29	9.4

Multivariable logistic regression analyses

Multivariable logistic regression models including geographical area, workplace setting, years of specialization, and sex showed that respondents practicing in Central Italy (OR 1.96, 95% CI 1.01–3.79) and Southern Italy/Islands (OR 3.46, 95% CI 1.52–7.87) had higher odds of reporting a marked increase in scabies cases compared with those in Northern Italy. Compared with dermatologists with <10 years of specialization, those with longer professional experience were more likely to perceive a marked increase.

For selection of combined therapy as first-line treatment, no significant associations emerged for geographical area or years of specialization after adjustment, whereas respondents working in university settings were significantly less likely than those in Hospital/IRCCS settings to select this approach (OR 0.12, 95% CI 0.02–0.65).

Regarding the perceived increase in permethrin treatment failures, geographical area and workplace setting were not significantly associated, whereas respondents with 20–29 years (OR 2.68, 95% CI 1.01–7.11) and ≥30 years of specialization (OR 3.56, 95% CI 1.40–9.10) had higher odds of reporting a perceived increase in treatment failures.

Systematic treatment of household contacts was less frequently reported by respondents practicing in Central Italy (OR 0.25, 95% CI 0.11–0.56) and by those working in private practice (OR 0.23, 95% CI 0.07–0.73). Selected significant adjusted associations are shown in Fig. 4.

Fig. 4.

Selected adjusted associations from multivariable logistic regression analyses. Forest plot showing adjusted odds ratios and 95% confidence intervals for clinically relevant outcomes, including perceived marked increase in scabies cases, more frequent permethrin treatment failure, and systematic treatment of household contacts

Discussion

This nationwide survey shows a strong consistency between clinicians’ perceptions and the broader epidemiological literature: almost all respondents reported an increase in scabies cases over the previous 3–5 years, and nearly three-quarters described this increase as marked. This aligns with reports from several European countries documenting a sustained rise in scabies incidence over the last decade [3–8] and supports the hypothesis that scabies in many high-income settings may increasingly behave as an infestation under sustained endemic pressure rather than sporadic outbreaks [12]. The post-COVID phase likely amplified pre-existing structural vulnerabilities such as social marginalization, overcrowding, and delays in accessing care.

Most dermatologists perceived the increase as involving all age groups rather than a specific age class. The high proportion reporting frequent diagnostic delay confirms that scabies remains challenging in routine practice, as it can mimic several pruritic dermatoses, present atypically, and be modified by prior empirical treatments [13, 14]. The widespread use of dermoscopy in our survey likely reflects an effort to improve diagnostic confidence.

The therapeutic findings are particularly relevant. The preference for combined topical and systemic therapy, which in routine clinical practice is likely to correspond mainly to a topical scabicide, most commonly permethrin, plus oral ivermectin, the principal systemic treatment currently used for scabies, together with the frequent perception of therapeutic failure suggests that scabies management is becoming increasingly complex. Current guidelines generally recommend permethrin or oral ivermectin as alternative first-line treatments for uncomplicated scabies, while concomitant topical and systemic therapy is primarily indicated for crusted or severe disease and may be considered after confirmed treatment failure [14, 15]. Therefore, if routinely adopted for uncomplicated cases, early combination therapy could represent unnecessary therapeutic escalation, increase drug exposure, and raise relevant stewardship concerns. It may also reflect clinicians’ declining confidence in permethrin efficacy. However, the survey did not specify the topical agent used, disease severity, previous treatments, or the clinical setting in which combination therapy was prescribed. Consequently, our findings cannot establish whether this approach represented inappropriate first-line escalation, management of severe or refractory disease, or lack of adherence to guideline recommendations. Moreover, these findings should not be interpreted as direct evidence of widespread acaricide resistance. Apparent treatment failure is often better explained by pseudo-resistance related to poor adherence, incorrect or incomplete application, failure to repeat treatment, untreated close contacts, reinfestation, or inadequate environmental decontamination, in line with recent guideline recommendations [16–18]. Although increasing permethrin treatment-failure rates have been reported, direct evidence of clinically relevant resistance remains limited. A recent systematic review reported an overall treatment failure prevalence of 15.2%, with relatively lower failure rates for permethrin and ivermectin, and no study directly assessed resistance [19]. Emerging evidence of reduced S. scabiei susceptibility over time and possible resistance mechanisms warrants attention [18, 20], but the relative contribution of pseudo-resistance is likely substantial.

Management of cohabitants emerged as another key issue. Most respondents reported systematic treatment of household contacts, consistent with current control principles, but this approach was not uniform across subgroups. Private practitioners were less likely to report systematic treatment of cohabitants. It may reflect the more episodic and individually focused nature of private consultations, limited integration with primary-care and public health pathways, and practical difficulties in ensuring that household members who are not present at the consultation receive and initiate treatment simultaneously. If the involved patient is treated while asymptomatic or inadequately treated contacts remain infested, reinfestation may occur despite initially effective therapy, sustaining reciprocal household transmission, the so-called “ping-pong effect.” These recurrent episodes may then be misinterpreted as pharmacological treatment failure, leading to repeated or intensified treatments and reinforcing the perception of pseudo-resistance [17, 18, 21].

Regional variation also deserves cautious interpretation. Dermatologists from Central and Southern Italy/Islands were more likely than those from Northern Italy to report a marked increase in scabies cases, which may reflect both true epidemiological differences and differences in case visibility across local healthcare settings. Clinicians with longer professional experience were more likely to report both a marked increase in cases and more frequent therapeutic failures, possibly because a longer frame of reference facilitates recognition of temporal changes.

These findings highlight the need for coordinated scabies control strategies. Priorities include improving early recognition, standardizing treatment and household-contact management, and strengthening notification pathways [22, 23]. General practitioners should be actively involved, as they often represent the first point of contact and can contribute to early diagnosis, first-line management, contact treatment, and timely dermatological referral in cases of diagnostic uncertainty, atypical or severe disease, or perceived treatment failure. Closer integration among general practitioners, dermatologists, and public health services could reduce diagnostic delays, reinfestation, and inappropriate therapeutic escalation. Moreover, incorporating general-practice data into surveillance systems could help determine whether the increasing burden documented by regional studies is also reflected in primary care [7, 10, 24]. However, dermatological referral is generally appropriate when the diagnosis is uncertain, in atypical or crusted presentations, in immunocompromised patients, during outbreaks, or when persistent symptoms require differentiation between active infestation, reinfestation, post-scabetic pruritus, and true treatment failure. No uniform national referral pathway appears to be available, and integration among general practitioners, dermatologists, and public health services may vary across regions and local healthcare systems. Moreover, professional scientific associations can play a key role in promoting education, disseminating practical recommendations, and fostering shared awareness across clinical settings. Particular attention should be paid to vulnerable populations such as older adults and immunocompromised, neurologic, or oncologic patients, who are at higher risk of severe forms, including crusted scabies, and secondary bacterial infections [25].

Limitations

This study has several limitations. Participation was voluntary and the survey was disseminated online, so selection bias cannot be excluded, and dermatologists with greater interest in scabies or recent exposure to cases may have been more likely to participate. The analysis was based on self-reported perceptions and practices rather than objectively verified epidemiological or prescribing data and is therefore subject to recall and reporting bias. The cross-sectional design precludes causal inference and does not allow temporal validation of the reported trends, and some subgroup analyses, particularly for smaller practice settings, should be interpreted with caution. The survey could not directly assess patient adherence to treatment regimens, and perceived therapeutic failure cannot be considered equivalent to confirmed drug resistance.

Conclusion

This nationwide survey suggests that Italian dermatologists perceive scabies as an increasingly frequent and clinically challenging condition, consistent with current epidemiological trends. Beyond the growing case burden, the findings highlight persistent diagnostic delays, frequent use of dermoscopy, concern about the effectiveness of first-line therapies, particularly permethrin, and relevant differences in management practices across settings and geographical areas. Overall, these results support the need for more standardized diagnostic and therapeutic pathways, better integration with public health procedures, improved access to treatment for both index cases and close contacts, and further studies integrating clinician perception with objective epidemiological and therapeutic outcome data.

Author contributions

Conceptualization, LF, ADG, CM; methodology, LF, FM; formal analysis; investigation, ADG, FM; data curation, ADG.; writing—original draft preparation, ADG, FM, ME, DLG, CL, RF, AL, SG, GLG, DP, DM, FA; writing—review and editing, ADG, FM, ME, DLG, CL, RF, AL, SG, GLG, DP, DM, FA; supervision, ADG, LF, CM All authors have read and agreed to the published version of the manuscript.

Funding

The present study was supported by Progetto Ricerca Corrente of Italian Ministry of Health.

Data availability

All data reported in the present manuscript will be available on request from the authors.

Declarations

Ethics approval and consent to participant

Electronic informed consent was obtained from all participants prior to access to the online survey. Participants were informed about the study aims and the anonymous nature of data collection, and submission of the completed questionnaire was considered to indicate consent to participate and to the use of anonymized, aggregated data for research purposes.

Institutional review board

The study was conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice guidelines. Due to the use of fully anonymized and aggregated data and the non-interventional design of the study, formal Ethics Committee/Institutional Review Board approval was waived.

Competing interests

The authors declare no conflict of interest.