The correct answer is B. Isotretinoin.

This patient has granulomatous rosacea (GR), a rare subtype of rosacea. Rosacea is a chronic inflammatory skin condition that affects the central face. UV exposure, spices, stress, exercise, and heat can exacerbate the condition. GR is very challenging to treat, becoming often treatment-resistant to the common topical (metronidazole, azelaic acid) and oral agents (low dose doxycycline at 50 mg/day or less). Since the patient failed to respond adequately to three months of doxycycline, the next best step is the initiation of isotretinoin. The typical isotretinoin dosing for GR is between 0.3-0.5 mg/kg/day. It has been demonstrated that isotretinoin had superior efficacy compared to doxycycline. The mechanism of action of isotretinoin is downregulation of the pro-inflammatory Toll-like receptor 2 (TLR2) expression on monocytes.

Oral metronidazole is not typically used to treat rosacea. Propranolol and other beta-blockers are used to treat the flushing or vascular aspect of rosacea (erythrotelangiectatic subtype) by vasoconstriction of the vessels. The patient does not have significant erythema and telangiectasias, so targeting the erythema and flushing would not be appropriate. Topical permethrin and ivermectin are both used to treat cutaneous demodicosis. Demodex mites are thought to play a role in rosacea pathogenesis by activating the TLR2 pathway. Tretinoin cream would not provide enough depth in terms of treatment and is inappropriate for granulomatous rosacea.

References:Two AM, Wu W, Gallo RL, Hata TR. Rosacea: part II. Topical and systemic therapies in the treatment of rosacea. J Am Acad Dermatol. 2015;72(5):761-772. doi:10.1016/j.jaad.2014.08.027
Park H, Del Rosso JQ. Use of oral isotretinoin in the management of rosacea. J Clin Aesthet Dermatol. 2011;4(9):54-61.
Erdogan FG, Yurtsever P, Aksoy D, Eskioglu F. Efficacy of low-dose isotretinoin in patients with treatment-resistant rosacea. Arch Dermatol. 1998;134(7):884-885. doi:10.1001/archderm.134.7.884

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