British Journal of Dermatology 2003; 148: 1125–1128.

Cutaneous Biology
A novel mutation in the keratin 4 gene causing
white sponge naevus
S-C.CHAO, Y-M.TSAI, M-H.YANG AND J.Y-Y.LEE
Department of Dermatology, National Cheng-Kung University Hospital, 138 Sheng-Li Road, Tainan, Taiwan

Accepted for publication 13 November 2002

Summary Background White sponge naevus (WSN) is a rare, autosomal dominant disorder that
predominantly affects noncornified stratified squamous epithelia, most commonly the buccal
mucosa. Clinically, WSN manifests as thickened spongy mucosa with a white opalescent tint in the
mouth and may be confused with other disorders that cause white lesions on oral mucosa. Recent
studies have identified pathogenic mutations in KRT4 and KRT13, the genes encoding mucosa-
specific keratins, in WSN.
Objectives To search for possible mutations in KRT4 and KRT13.
Methods We report a case of WSN in a young man who presented with diffuse irregular whitish
plaques involving the buccal and gingival mucosae and the tongue.
Results Pathologically, the affected mucosa showed epithelial thickening, parakeratosis and
extensive vacuolization of the suprabasal keratinocytes. Mutation analysis revealed a heterozygous
missense mutation 1345G fi A in KRT4, predicting an amino acid change, E449K, in the 2B
domain of the K4 polypeptide.
Conclusions We report the first mutation analysis of a Taiwanese patient with WSN. Potentially
this novel mutation could disrupt the stability of keratin filaments and result in WSN.
Key words: KRT4, mutation analysis, white sponge naevus, WSN

White sponge naevus (WSN; OMIM 193900) is a rare,
autosomal dominant disorder that almost invariably
affects the oral mucosa, and less frequently extra-oral
sites, including the mucous membrane of the nose,
oesophagus, rectum, and vulvovaginal mucosa.1–3 The
condition usually manifests in early childhood or in the
first decade of life. Clinically it is characterized by
thickened spongy mucosa with a white opalescent tint,
in the mouth, particularly the buccal mucosa, and may
be confused with other white lesions of the oral
mucosa, such as cheek biting, lichen planus, lupus
erythematosus, pachyonychia congenita and candido-
sis. Histologically, WSN shows epithelial thickening,
parakeratosis, and extensive vacuolization of the
suprabasal keratinocytes.
The suprabasal keratinocytes of the buccal, nasal,
oesophageal mucosa, and anogenital epithelia specific-
Correspondence: J. Yu-Yun Lee MD.
E-mail: yylee@mail.ncku.edu.tw
ally express K4 and K13.4,5 Recently, mutations in
KRT4 and KRT13 genes have been associated with
WSN.6–11 Here we report a Taiwanese family with
WSN, and the identification of a novel pathogenic
mutation in KRT4 gene in this kindred.
Case report
A 23-year-old Taiwanese man in generally good
condition noted asymptomatic, whitish coating over
the buccal mucosa, gum, and lateral aspect of the
tongue since he was in junior high school. He had
visited several dentists and candidosis was suspected.
Nystatin suspension was prescribed but was ineffective.
He was referred to the department of Dermatology,
National Cheng-Kung University Hospital, for further
evaluation. The patient was seen to have diffuse,
whitish plaques involving the buccal mucosa, gum and
lateral aspect of the tongue. The surface was rough
because he often bit off the whitish mucosa (Fig. 1). His

 2003 British Association of Dermatologists 1125

1126 S - C . C H A O et al.
Figure 1. White sponge naevus in buccal mucosa (A,B) and labial
mucosa (C,D).
anal and nasal mucosae were unaffected. A potassium
hydroxide (KOH) mount did not find evidence of
Candida. The pedigree showed that only his father
was similarly affected (Fig. 2). A biopsy specimen of the
buccal mucosa revealed hyperkeratosis with parakera-
tosis and diffuse vacuolization of the suprabasal kera-
tinocytes (Fig. 3).
 2003 British Association of Dermatologists, British Journal of Dermatology, 148, 1125–1128
Figure 2. The family pedigree. j, affected male; h, unaffected male;
s, unaffected female; arrow denotes the proband.
Figure 3. Histopathology reveals parakeratosis and prominent vac-
uolation of the spinous cells in the buccal mucosa (haematoxylin and
eosin stain, original magnification · 100).
DNA extraction and polymerase chain reaction
amplification
Genomic DNA was extracted from peripheral blood of
the patient and nuclear family members (QIAamp Midi
kit; Qiagen, Valencia, CA, U.S.A.). DNA samples were
then subjected to mutation screening by amplification
of segments of KRT4 gene using primers synthesized on
 KRT4 GENE MUTATION IN WHITE SPONGE NAEVUS 1127

the basis of intronic sequences from GenBank

(AY043326).
For polymerase chain reaction (PCR) amplification,
approximately 200 ng of genomic DNA, 12Æ8 pmol of
each primer, 10 lmol dNTP and 1Æ25 U of Taq (Qiagen,
Chatsworth, CA, U.S.A.) were used in a total volume of
50 lL. The amplification conditions were 94 C for
5 min, followed by 40 cycles of 94 C for 45 s,
annealing temperature 50 C for 45 s and 72 C for
45 s, and extension at 72 C for 10 min. The primers
used for the amplification of exon 5 were: forward
primer, 5¢-CTA TGG CTG GAG TGA ATG AG-3¢;
backward primer, 5¢-CGG CAG AGG CAT AAA TAA
GC-3¢; and sequence primer 5¢-CAG CGA GGT GAG
AAT GCC CT-3¢. The product size was 459 bp. PCR
products were purified by QIAquick columns (Qiagen)
and sequenced with both forward and reverse primers
(377 ABI; Advanced Biotechnologies, Columbia, MD,
U.S.A.).
Direct sequence showed a nucleotide substitution
G fi A at position 1345 in KRT4 (Fig. 4), resulting in a
missense mutation E449K. The mutation removed a
restriction enzyme site (TaqI). The mutation was
confirmed by restriction fragment analysis. The muta-
tion was found only in the proband and his father and
not in the unaffected family members or 100 alleles
from 50 normal unrelated Taiwanese controls, indica-
ting that this mutation was not a polymorphism (data Figure 4. A, Automated sequencing of the KRT4 gene (codons 446–
not shown). 451) with a sense primer reveals a heterozygous change from G to A
in the first position of codon 449, predicating a substitution of
glutamic acid by lysine (E449K) in the patient. B, sequence with
Discussion reverse primer.

We have presented a case of WSN with typical clinical

and pathological features and identified a novel mis- Table 1. Summary of mutations found in patients with white sponge
naevus
sense mutation in KRT4 gene. Ultrastructural studies
on WSN have shown that there is compact aggregation K4 mutation K13 mutation
of keratin intermediate filaments in the upper spinous Mutation Domain Reference Mutation Domain Reference
layers resembling those found in epidermal disorders 160delN 1A 7 M108T 1A 8
associated with keratin defects.12,13 The restriction of 153–154insQ 1A 10 N112S 1A 11
lesions to mucosal epithelia and pathological changes E449K 2B Present L115P 1A 8
to the suprabasal cells in WSN parallels the tissue- study L119P 1A 6

specific expression of K4 and K13 in the differentiating

cell layers. Recently, Richard et al.6 reported a point
mutation in KRT13 and Rugg et al.7 reported muta-
tions of the KRT4 in WSN. To date, six pathogenic
mutations have been identified in KRT4 and KRT13,
including four missense mutations (Table 1).6–11
Intermediate filaments (IFs) are key components of
the cytoskeleton in higher eukaryotic cells. The poly-
peptide building blocks of all IFs have a similar
backbone structure. The elementary IF building block
is an elongated coiled-coil dimer consisting of four
consecutive a-helical segments (1A, 1B, 2A, 2B). The
segments 1A and 2B include highly conserved
sequences and are critically involved in IF assem-
bly.14–19 Numerous pathogenic mutations have been
found within these regions (1A, 2B) underlying a wide
range of epithelial diseases.20 The previously reported
mutations in WSN all occurred in the 1A domain.

 2003 British Association of Dermatologists, British Journal of Dermatology, 148, 1125–1128

1128 S - C . C H A O et al.
In this study we detected a novel mutation E449K in
the highly conserved region of the 2B domain. This
residue is conserved in all intermediate filament
proteins of all species cloned to date, and a mutation
in the same position was reported in KRT1 in
epidermolytic hyperkeratosis21 and in K2e in ichthyosis
bullosa of Siemens.22 This mutation may disturb the
stability of the filaments by disrupting the recently
reported interhelical salt bridge.19
In the differential diagnosis of WSN, oral lesions of
leukoplakia, chemical burns, trauma, tobacco or betel
nut use, and syphilis are sufficiently different from the
white plaques of WSN in clinical and microscopic
appearances. WSN may be confused with candidosis;
however, fungal examination, the histology of biopsy
specimens, and the response to antifungal agents will
differentiate the two. Lesions of pachyonychia congen-
ita, hereditary benign intraepithelial dyskeratosis,
Darier’s disease, dyskeratosis congenita, lichen planus,
and lupus erythematosus may resemble those of WSN.
Except for lichen planus and, rarely, lupus erythema-
tosus, which may be limited to the oral cavity, these
disorders can be distinguished clinically from WSN by
their associated extraoral lesions. The histopathology of
these conditions is also very different.
Treatment with vitamins, antihistamines and mouth
rinses have been recommended, but none has been
successful.23,24 Penicillin was thought to have led to
remission in two patients with WSN.25 The efficacy of
tetracycline mouth rinse has been reported.26,27 How-
ever, most doctors suggest that reassurance is all that is
required.
In conclusion, we have reported the first mutation
analysis of a Taiwanese patient with WSN. The novel
mutation in the KRT4 gene could potentially disrupt the
stability of keratin filaments and thus result in WSN.
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