Abhi, this is clinically very suggestive of a lichenoid drug eruption due to metoprolol.

👉 Onset 6 months after starting metoprolol fits perfectly with drug-induced lichen planus (usually weeks to months).

🔎 What This Likely Is

✅ Lichenoid Drug Eruption (LDE)

• Triggered by medications (beta blockers are known causes)

• Looks like classical lichen planus

• Appears months after drug initiation

• Improves after stopping the offending drug

Metoprolol is a documented cause.

📋 What You Should Do (Clinical Approach)

1️⃣ Confirm Timeline

• Lesions started after metoprolol?

• Any other new drug added in last 6–12 months?

  • NSAIDs?

  • ACE inhibitors?

  • Antimalarials?

  • Thiazides?

If metoprolol is the only new drug → strong suspicion.

2️⃣ Don’t Stop Abruptly

⚠ Very important
Metoprolol must be tapered, not stopped suddenly.

3️⃣ Switch Antihypertensive

Since patient also had tachycardia (as you mentioned earlier), best alternatives:

✔ Diltiazem (if no heart failure)

• Controls BP

• Controls HR

• Good substitute

OR

✔ ACE inhibitor (e.g., Ramipril)

If tachycardia is mild and secondary.

Avoid:

• Amlodipine alone (may worsen tachycardia)

• Hydralazine

4️⃣ Dermatology Management

• Topical high-potency steroid (Clobetasol)

• Antihistamine if itching

• Oral steroids only if severe

Lesions usually improve within weeks–months after withdrawal.

🎯 My Clinical Suggestion

If:

• Clear timeline

• No other new drugs

• No other trigger

👉 I would gradually taper metoprolol and shift to Diltiazem, unless contraindicated.