Generalized pustular psoriasis (GPP) is a rare disorder affecting about 2 per million individuals in Europe (Augey et al., 2006).This severe disease is characterized by repeated flare-ups of pustules and can be accompanied by a potentially life-threatening multisystemic inflammation.Recently, missense mutations in IL36RN have been identified in GPP patients from Tunisia and Europe (Marrakchi et al., 2011; Onoufriadis et al., 2011).In addition, a stop mutation, a novel missense mutation, and mutations affecting splicing of exon 3 have been observed in Japanese patients (Sugiura et al., 2012; Farooq et al., 2013).A group of 19 patients were recruited at five German university hospitals and one specialized dermatol. hospital.In all, 17 patients suffered from typical symptoms of GPP, one patient from psoriasis vulgaris (PsV) with repeated flares of generalized grouped pustules without fever, and another one from PsV with pustules (P19).The three-dimensional structure of human IL36RA was modeled with SwissModel (Guex et al., 2009) using the high-resolution crystal structure of murine IL-1F5 as a template (PDB code: 1MD6; Dunn et al., 2003).Promising variants possibly affecting the structure of IL36RA were generated with SwissModel (Guex et al., 2009), selecting the lowest-energy rotamer for each mutated side chain.We identified homozygous/compound heterozygous variants in seven patients: four patients were homozygous for p.His32Arg, p.Pro76Leu, or p.Ser113Leu, and three further individuals were compound heterozygous for p.Ser113Leu and either p.Arg48Trp, p.Glu94X, or p.Pro76Leu.The stop mutation and the two missense variants p.His32Arg and p.Pro76Leu were, to our knowledge, previously unreported, all affecting highly conserved residues. p.Glu94X disrupted the globular cytokine fold (Figure 1b).His32Arg was not expected to have a significant effect on IL36RA structure/stability, but it possibly has an effect on the interaction with its receptor.Arg48Trp not only affects IL36RA stability, but also affects receptor binding.Four online prediction tools support damaging effects of p.Arg48Trp, p.Pro76Leu, and p.Ser113Leu, whereas the rare variant p.His32Arg was predicted to be neutral (Supplementary Table 1 online).All available unaffected parents of patients (five families) tested as heterozygous mutations carriers.An addnl. coding variant (p.Ser200Asn, according to NM_024110) in CARD14, more recently shown to be relevant for the pathogenesis of PsV and GPP (Jordan et al., 2012a, 2012b), was identified in P02, who developed disease at age 1 yr, but not in P05, whose disease manifested at the age of 17 years (Supplementary Table 2 online). p.Sanger sequencing of CARD14 in another 17 patients revealed three rare variants (rare allele <1%) in two patients (Table 1, Supplementary Table 2 online): p.Located in the CARD domain, it is predicted to be damaging by various anal. tools.We therefore regard it as a contributing factor to P14's GPP.Described to cause autosomal dominant inherited PsV (Jordan et al., 2012b), P08's mutation p.Gly117Ser is probably responsible for long-existing PsV, whereas the addnl. heterozygous IL36RN mutation may have induced his first GPP episode.Our rate of 38.9% IL36RN mutations provides further evidence that GPP is heterogeneous.As such, revealing the mol. basis of GPP in single patients may be clin. important for therapeutic decision making.