A 72-year-old female presents with vulvular pruritus and lesions on the vulva. What should be the next step in management?

In the case of a 72-year-old female presenting with vulvar pruritus and lesions on the vulva, the most appropriate next step in management is to refer the patient to a gynecologist for biopsy. This approach is essential for several reasons.

Firstly, the presence of lesions, combined with pruritus, raises the suspicion for various dermatological conditions or even malignancies such as vulvar squamous cell carcinoma or other vulvar dystrophies. A biopsy is crucial to obtain a definitive diagnosis, allowing for appropriate treatment to follow based on the specific pathology identified.

Secondly, while topical treatments like steroids or estrogen creams may alleviate symptoms, they do not address the underlying cause of the lesions. Given the patient's age and presentation, a direct evaluation through biopsy ensures that any serious conditions are ruled out or confirmed promptly.

The other management strategies would not provide the same level of diagnostic specificity or assurance, making referral for biopsy the most prudent initial management step in this scenario.