INTRODUCTION: Purpura fulminans (PF) is a devastating complication of uncontrolled systemic inflammation, associated with high incidence of amputations, skin grafts and death. In this study, we aimed to clarify the clinical profile of pediatric patients with PF who improved with protein C (PC) treatment, explore treatment effects and safety, and to refine the prognostic significance of protein C plasma levels. METHODS: In Germany, patients receiving protein C concentrate (Ceprotin, Baxter AG, Vienna, Austria) are registered. The database was used to locate all pediatric patients with PF treated with PC from 2002 to 2005 for this national, retrospective, multi-centered study. RESULTS: Complete datasets were acquired in 94 patients, treated in 46 centers with human, non-activated protein C concentrate for purpura fulminans. PC was given for 2 days (median, range 1-24 days) with a median daily dose of 100 IU/kg. Plasma protein C levels increased from a median of 27 to a median of 71 under treatment. 22.3 of patients died, 77.7 survived to discharge. Skin grafts were required in 9.6 , amputations in 5.3 . PF recovered or improved in 79.8 , remained unchanged in 13.8 and deteriorated in 6.4 . Four adverse events occurred in 3 patients, none classified as severe. Non-survivors had lower protein C plasma levels (P <0.05) and higher prevalence of coagulopathy at admission (P <0.01). Time between admission and start of PC substitution was longer in patients who died compared to survivors (P = 0.03).