Part of the Hidradenitis Suppurativa Knowledge Library
Two patients arrive with the same Hurley stage, the same sites, lesions that photograph almost identically — and one responds to treatment while the other does not. Staging alone does not explain that. Something has to account for which part of the process is dominant in a given person, because that is what decides what the treatment has to do first.
The Pancha Maha Bhootas — the five elements — are the framework we use for that. Below, each one is set out with what it governs, how it tends to show up in HS, and what it corresponds to physiologically. That last column is the point. A framework that cannot be cashed out in mechanism is decoration.
HS is not one process. It is inflammation, plus a barrier and follicular problem, plus a healing and remodelling problem, plus a regulatory problem — running at different intensities in different people. Treating it as a single thing is why "one protocol for everyone" fails.
What a framework does is force the question which of these is loudest here before anything is prescribed. Used well it is a triage instrument. Used badly it is vocabulary. The difference is whether each term maps onto something observable.
Earth governs structure, tissue integrity and physical resilience. Where it is weakened or overloaded, the body loses its capacity to maintain healthy tissue and to heal cleanly.
In HS this tends to appear as: hardened lesions, deep nodules, sluggish healing, tissue congestion, and scarring that accumulates faster than it resolves.
Physiologically: this is the repair-and-remodelling arm of the disease — disordered collagen deposition and fibrosis, the same process that turns a resolved lesion into a permanent tract wall. It is also the part of HS that does not reverse. Scar is structural, and no internal treatment dissolves it, ours included. Recognising Earth as dominant changes the goal: preventing further structural loss, rather than promising to undo what is already there.
Water governs fluid balance, circulation and clearance. Disturbed, fluids stagnate rather than move.
In HS this tends to appear as: pus formation, drainage, swelling, inflammatory discharge, and a persistent sense of internal congestion.
Physiologically: exudate production and impaired lymphatic clearance. Inflammatory exudate is protein-rich; where it is produced faster than it can be cleared, it pools in tissue and in tracts, which is both the drainage a patient sees and the substrate behind the odour. This is the arm of the disease that usually moves first under treatment, which is why drainage is one of the markers we track rather than leading on how the skin looks.
Fire governs metabolism, transformation, heat, hormonal activity and the inflammatory response. In many HS patients it is the aggravated element: a body held in chronic inflammatory overactivation.
In HS this tends to appear as: burning inflammation, painful flares, redness and heat, aggressive recurrence, and frequently metabolic and digestive disturbance alongside the skin.
Physiologically: sustained pro-inflammatory cytokine signalling, with the metabolic and androgenic drivers that keep feeding it. This is the arm biologics target, and they target it well — which is precisely why the disease returns when they stop, if nothing upstream changed. Calming Fire is not the same as suppressing it; the aim is to change what keeps provoking it.
Air governs movement, nervous-system regulation and the stress response. Disturbed, the body becomes unpredictable.
In HS this tends to appear as: sudden flares, irregular recurrence patterns, stress-triggered inflammation, heightened pain sensitivity, and disrupted recovery. Most patients notice that poor sleep or a bad month at work shows up on their skin.
Physiologically: autonomic and HPA-axis involvement — sustained stress raising cortisol and shifting inflammatory signalling. This is also the element that explains climate and seasonal patterns: heat, humidity and sweating aggravate an already-inflamed fold. That makes them a trigger, not a cause, and the distinction matters.
Ether governs space, internal communication and the coordination between systems. Where it is disturbed, the body loses coherent self-regulation.
In HS this tends to appear as: the sense many patients describe of the body fighting against itself — healing slowing, inflammation becoming cyclical rather than episodic, recovery never quite completing.
Physiologically: immune dysregulation. Not an immune system that is too weak or too strong, but one responding to the wrong things at the wrong times. This is the element that most often explains why treating the skin alone plateaus.
If Water is dominant, clearance and drainage come first and the patient sees change early. If Fire is dominant, the inflammatory load has to come down before anything else will hold. If Earth is dominant, expectations change — the honest goal is halting progression, not reversal. If Air is dominant, the trigger environment matters as much as the formulation. If Ether is dominant, it is a longer piece of work and it should be said so at the start.
This is what "we treat your driver profile, not your diagnosis" means in practice. Two people with identical staging get different formulations because the framework says different things are loudest.
It is a way of organising clinical observation. It is not a claim that the five elements have been demonstrated as mechanisms in the sense a randomised trial would require, and we are not going to present it as one.
What can be said is narrower and more useful: each element in this framework corresponds to something observable and measurable — fibrosis, exudate and lymphatic clearance, cytokine and hormonal activity, autonomic regulation, immune coordination. The framework is the lens; those are the things actually being treated and tracked. If the lens ever stopped corresponding to them, it would be the lens that was wrong.
That is also why we publish no success rate, and why outcomes are judged from month eight rather than month two. A framework is only worth using if it survives contact with what actually happens to patients.
