To characterize keratin intermediate filament assembly mechanisms at atomic resolution, we determined the crystal structure of wild‐type human keratin‐1/keratin‐10 helix 1B heterotetramer at 3.0 Å resolution. It revealed biochemical determinants for the A11 mode of axial alignment in keratin filaments. Four regions on a hydrophobic face of the K1/K10‐1B heterodimer dictated tetramer assembly: the N‐terminal hydrophobic pocket (defined by L227K1, Y230K1, F231K1, and F234K1), the K10 hydrophobic stripe, K1 interaction residues, and the C‐terminal anchoring knob (formed by F314K1 and L318K1). Mutation of both knob residues to alanine disrupted keratin 1B tetramer and full‐length filament assembly. Individual knob residue mutant F314AK1, but not L318AK1, abolished 1B tetramer formation. The K1‐1B knob/pocket mechanism is conserved across keratins and many non‐keratin intermediate filaments. To demonstrate how pathogenic mutations cause skin disease by altering filament assembly, we additionally determined the 2.39 Å structure of K1/10‐1B containing a S233LK1 mutation linked to epidermolytic palmoplantar keratoderma. Light scattering and circular dichroism measurements demonstrated enhanced aggregation of K1S233L/K10‐1B in solution without affecting secondary structure. The K1S233L/K10‐1B octamer structure revealed S233LK1 causes aberrant hydrophobic interactions between 1B tetramers.