Gain-of-function variant in NNT causes premature diffuse familial sebaceous hyperplasia

Premature diffuse familial sebaceous hyperplasia (PDFSH) constitutes a distinct clinical variant of sebaceous hyperplasia, characterized by three hallmark features: early disease onset; characteristic sparing of the perioral and periocular regions; and a positive family history. To date, the pathogenic gene underlying PDFSH has remained unidentified.

To identify the underlying genetic cause and pathogenesis of three familial cases of autosomal dominant PDFSH.

Whole-exome sequencing was performed in two unrelated families with autosomal dominant PDFSH. In an additional patient, using Sanger sequencing, the identified candidate gene was further screened for variants. The ultrastructure of sebaceous glands was analysed by transmission electron microscopy. Immunofluorescence staining was done to assess lipid peroxidation levels in sebaceous glands. Functional analyses included quantification of the NADPH/NADP+ ratio, and glutathione and reactive oxygen species (ROS) levels. Flow cytometry with C11-BODIPY and propidium iodide staining was performed to assess lipid peroxidation and cell viability, respectively.

We identified a missense variant c.2063T>G (p.Leu688Trp) in NNT in all affected members across the three families with PDFSH. Patient-derived keratinocytes and nicotinamide nucleotide transhydrogenase (NNT)-knockdown SZ95 sebocytes overexpressing mutant NNT exhibited enhanced antioxidant capacity, as shown by an elevated NADPH/NADP+ ratio, increased glutathione levels and decreased production of ROS vs. controls. Ultrastructural analysis revealed a decreased proportion of mitochondria with cristae disorganization; immunofluorescence staining showed reduced levels of lipid peroxidation in the patients' sebaceous glands, suggesting decreased susceptibility to ferroptosis. In vitro experiments confirmed that the NNT c.2063T>G variant protects SZ95 sebocytes from ferroptosis by mitigating oxidative stress.

We identified a gain-of-function variant [c.2063T>G (p.Leu688Trp)] in NNT underlying PDFSH. This genetic variant enhances the antioxidant capacity of NNT, while attenuating intracellularly accumulated ROS levels, and reduces sebaceous glands' susceptibility to ferroptosis.